Recent years have seen considerable research into the health and social welfare needs of disadvantaged populations, including refugees and asylum seekers. Developing appropriate national and local-level policy in the UK to address these needs has lagged behind. Recent research on behalf of the Welsh Refugee Council, for example, concluded that service provision for refugees in Wales could be understood only in terms of three cultures: "ignorance, disbelief and denial"(1) . In many areas of London refugee health services, provided through combinations of statutory and voluntary sector agencies, have been poorly funded and resourced and not been tailored to the needs of refugees.
Croydon Health Authority in South West London conducted a health needs assessment among local refugee communities in 1999. The research was conducted in response to increasing concerns among local interest groups, politicians and the statutory services that the number of refugees in Croydon was rising and that health needs in this vulnerable population were poorly defined and perhaps largely going unmet. Ultimately, the work was used to develop an action plan to tackle local health inequality and became an important theme within the Croydon Health Improvement Plan 1999-2002.
At the end of this process we wanted to explore the influence of our research on local policy:
- Was our research influential in its own right or simply because it was carried out in the right place, at the right time?
- How important was the process by which research was carried out compared to the research findings themselves?
- What lessons are there for other researchers and advocates of refugee health?
Right place, right time?
There was growing awareness of the need to quantify and prioritise refugee health needs in London and in Croydon. In early 1998, the Health of Londoners Project (HoLP) decided to assess the health needs of refugees living in London. Croydon Health Authority became aware of increased public concern regarding the number of refugees living locally and was asked to provide information on refugee health by Croydon Council. This favourable local environment was complemented by the commitment of the newly-elected Labour government to tackle health and social inequality. New emphasis on partnership with local stakeholders helped ensure our research found a receptive audience.
The war in Kosovo focused attention on refugees and refugee health issues. Airlifts of civilian casualties to Britain in April 1999 led the Department of Health to recommend that all local authorities and health authorities collaborate in developing emergency contingency plans. Research previously conducted by health authorities, NGOs and others was circulated via an electronic public health network. At local level we were encouraged to build on local partnerships formed during our participatory research and to discuss our research findings more widely. Prior to the Kosovo crisis negative articles in the local media about Roma refugees from the Czech Republic were followed by reports of vandalism at refugee community centres. Kosovo helped promote more balanced media coverage of issues relating to refugees and asylum seekers. Local journalists became interested in our work and we provided background information for a number of articles. Media attention raised awareness among local health staff and policy makers, many of whom were previously reluctant to discuss these issues.
Content or process?
The broad focus of much UK-based research in refugee health has made it difficult for policy makers to apply study findings at local level. Research has tended to focus on broad issues common to many refugee communities. It has been difficult for health authorities to prioritise different refugee health needs because the Home Office is unable to provide demographic data at local authority level detailing the total numbers of resident refugee populations or their country of origin, age, gender or household composition.
Our research clarified refugee health and welfare needs at local level and presented findings in a way that was clear to those making policy decisions. By comparing data from a variety of sources, we were able for the first time to provide policy makers with reliable demographic estimates. Recommendations and priorities for local action were put forward that recognised existing priorities and the capacity of local health and social services. We realised that ideas perceived both as locally acceptable and attractive in terms of capital investment were more likely to be incorporated into policy.
The content of our research and the way it was presented seems to have been an important factor in promoting our recommendations into policy but what of the research process? We used participatory methods that facilitated joint working practices, sharing of information and local ownership of research findings. Many areas for future policy and service development, such as the training of peer-educators, were highlighted. Local refugee interest groups played an essential role as key informants and participants in the rapid appraisal. Their recommendations were included in the Croydon Health Improvement Plan and used to inform models for local primary care development. The action-orientated nature of the research process helped consolidate a network of local organisations and facilitated the development of a multi-agency planning group to take forward key recommendations such as developing bilingual health advocacy services.
During the process of collecting, verifying and comparing data, informal networks were established between the Health Authority, Community NHS Trust and the Local Authority Housing and Social Services Departments. Regular progress updates and wide-ranging consultation prior to the publication of a final report kept stakeholders and policy makers involved, fostered a sense of ownership of the research findings and built support for later policy development work.
Lessons learned?
Our research was used to prioritise refugee health within the local public health context and to select key issues for consideration whilst rejecting others. Some of our influence seems to have simply been a case of right place, right time: broad political and policy factors were favourable. The way in which we presented our findings and the methods we used were also significant.
Being aware and taking advantage of favourable factors that promote the incorporation of research into local policy is important. Advocates of policy change for refugee health should not rely on research findings alone to influence public health policy and action at local level.
Andrew Vallely, formerly Senior House Officer, Croydon Health Authority, London, now works with the DFID Eastern Africa HIV/AIDS Prevention & Care Project in Kenya. Email: andrew@futures.co.ke
Catherine Scott is a Public Health Specialist with the Croydon Primary Care Trust. Email: catherine.scott@croydonpct.nhs.uk
Notes
- V Robinson 'Cultures of ignorance, disbelief and denial: refugees in Wales', Journal of Refugee Studies, 12(1), pp78-87.