Diversity-mainstreaming in times of ageing and migration: implementation paradoxes in municipal aged care provision

ABSTRACT

Accompanying a shift from multiculturalism to assimilation in integration discourse, several European immigration countries have shifted from multiculturalist to diversity-mainstreaming policies in the aged care sector. This paper answers the question to what extent diversity-mainstreaming policies provided scope for crafting care provision that is responsive to the needs of ethnic minority elders. To study the implementation of diversity-mainstreaming policies in aged care we conducted a two-year qualitative study in Nijmegen and The Hague, The Netherlands. We identified a mix of mainstreamed and ethno-specific aged care provision which reflected stakeholders’ ongoing practical concern with diversity among ethnic minority elders. Nevertheless, we found diversity-mainstreaming policies to be plagued by implementation paradoxes. In some interpretations, ‘diversity’ inhibited concrete action to address inequality experienced by ethnic minorities. When ‘diversity’ did provide space to tailor services, these were framed as temporary responses to the language barriers of the current generation of ethnic minority elders. We found this assimilationist framing to undermine long-term investment in the local knowledge needed to reach minority elders. We suggest that policymakers renew support for ethno-specific services and intercultural expertise to successfully meet the diverse care needs of current and future generations of older minority populations.

KEYWORDS:

• Diversity
• inclusion
• older migrants
• mainstreaming
• eldercare

Introduction

In the past, the Netherlands was at the forefront of health care policies targeting migrants and ethnic minorities in Europe (Mladovsky et al. 2012). However, due to a growing disaffection with policies aimed at supporting minority groups, subsidies for intercultural¹ programmes and institutes were withdrawn in the early 2000s in favour of diversity-mainstreaming policies (Helberg-Proctor et al. 2017). This strategy has been defined as ‘the effort to embed diversity in a generic approach across policy areas as well as policy levels, to establish a whole-society approach to diversity rather than an approach to specific migrant groups’ (Van Breugel and Scholten 2017, 512), and has become the preferred national strategy to govern the increasingly ‘super-diverse’ populations of European countries such as the Netherlands, Great Britain, Belgium and France (Vertovec 2010; Boccagni 2015).

This transition to diversity-mainstreaming policies will, undoubtedly, have affected care provision for ethnic minority elders. However, to our knowledge, little research has been conducted on how diversity-mainstreaming affects aged care (for an exception see Brandhorst, Baldassar, and Wilding 2019). This constitutes a significant gap since ethnic minority elders represent a growing population not only in the Netherlands, but in many immigration countries (De Valk and Fokkema 2017). Furthermore, a large share of this population experiences worse health conditions than their counterparts in the majority population, and they are known to underuse aged care services (Greenwood et al. 2015; De Valk and Fokkema 2017). One reason for why this is the case is the lack of sensitivity to diverse needs and preferences within care services (Ahaddour, Van den Branden, and Broeckaert 2016; Chaouni Berdai, Smetcoren, and De Donder 2020). Therefore, this paper sets out to answer the research question: ‘how does the implementation of diversity-mainstreaming policies in aged care provision affect the scope for local stakeholders to address the care needs of ethnic minority elders?’

To answer the above question, we conducted a two-year (June 2017–July 2019) qualitative study of how diversity-mainstreaming policies were implemented in aged care for older people in Nijmegen and The Hague, the Netherlands. We focus on the urban level since the Netherlands, like Germany and the UK, has seen a transition not only to diversity-mainstreaming but also to localisation² of service provision (Bailey and Pill 2011). To analyse the implementation of national diversity-mainstreaming policies at the urban level, we, therefore, draw on literature in Public Administration studies on policy implementation of the localisation of aged care services (Durose 2007; Bannink, Bosselaar, and Trommel 2013). More specifically, we use the concept of ‘crafting practices’ as our analytical framework (Bannink, Bosselaar, and Trommel 2013).

The term ‘crafting practices’ refers to how policies are implemented in localised contexts. Bannink, Bosselaar, and Trommel (2013) use it since they found policy implementation to be a relatively open process, which develops through working relationships between local stakeholders, and through the learning that takes place in these relationships (hence ‘crafting’, after Sennett 2008). They argue that for crafting practices to succeed in tailoring service provision to the local population, two elements are necessary. ‘Crafting space’ which refers to political empowerment granting room to model new practices and ‘Crafting tools’, referring to ‘technical resources (e.g. money, staff, skills) as well as institutional and/or symbolic ones (e.g. legitimacy, support, ideas)’ (Sennett 2008, 16). To study the extent of which diversity-mainstreaming policies provided local stakeholder with crafting tools and crafting space, we conducted 44 semi-structured interviews, 295 h of participant observation and analysis of municipal policy documents. We included policymakers, managers of health, social and aged care organisations and frontline workers since these actors have been found to be involved in policy implementation (Bartels 2018; Nugus et al. 2018).

We found that crafting practices resulted in a mix of diversity-mainstreaming initiatives, in the form of diversity networks, and ethno-specific eldercare, in the form of intercultural eldercare advisors and day and home-care services, in both cities. While this service mix was the result of deliberate crafting processes and reflected an ongoing practical concern with existing diversity among older migrants and ethnic minorities, we question whether diversity-mainstreaming policies are suitable to address the care needs both of current and future super-diverse older populations.

Our findings show that diversity-mainstreaming policies are plagued by two related implementation paradoxes. The first one is that the vagueness of the term ‘diversity’ creates ambiguous crafting space. In some interpretations of ‘diversity’ it inhibited concrete action to address inequalities experienced by ethnic minorities. When the interpretation of ‘diversity’ did provide crafting space, we encountered a second implementation paradox. Although stakeholders had enough crafting space to respond to current care needs, the diversity-mainstreaming discourse elicited an assimilationist framing which undermined necessary crafting tools in the long term. For example, ethno-specific services were framed as a response to ‘temporary’ populations with special, notably language-related needs which were assumed to disappear with the next generation. We argue that framing these services as temporary undermines investment in the intercultural expertise we found to be necessary to reach out to and engage ethnic minority elders.

The article proceeds as follows: to provide context to our study, we explain the waning political support for migrant-related health policies in the Netherlands through three interrelated shifts. The first is a shift from multiculturalism to assimilationism in societal discourses on immigrants and ethnic minorities. The second is a shift from targeted health and social care policies for minority groups to diversity-mainstreaming policies. This is accompanied by a third shift towards localism in the governance of social care, in which service uses are framed as members of local communities rather than ethnic minority groups. We proceed by reviewing the related literature in Public Administration and Urban Studies on diversity-mainstreaming in Europe through the lens of ‘crafting practices’. After discussing our research approach, we then present our findings. We conclude with a discussion of the long-term implications of diversity-mainstreaming policies and suggest that policymakers should meet the care needs of increasingly ethnically and culturally diverse populations by affirming difference rather than assuming future assimilation.

Crafting health and social care in the post-multiculturalist Netherlands

In the Netherlands, a shift from multiculturalism to assimilationism has taken place over the course of two decades, starting in the 1990s with the rise of societal concerns about the relatively negative outcomes of citizens with a non-Western migration background in statistics on education, labour market participation and crime (Schinkel and Van Houdt 2010; Westerveen and Adam 2019). Whereas previously, differences between citizens with and without a migration background were mostly attributed to structural inequalities, which were to be addressed through targeted policies to support minorities, since the late 1990s the responsibility for closing societal gaps was increasingly put on the shoulders of immigrants and ethnic minorities themselves (Schinkel and Van Houdt 2010; Westerveen and Adam 2019). As part of the shift towards assimilationism, people with a migration background were also expected to identify more with an (imagined) Dutch community than with an ethnic minority group.

Policy-wise, the growing dominance of assimilationist ideals has had the implication that policies intended to emancipate minority groups, often through the support of ethnic minority self-organisations, have been gradually abandoned. Health policies have also been influenced by the shift in national integration discourse and the subsequent policy changes. In the past, the Netherlands served as a leading example of migrant health provision in Europe (Mladovsky et al. 2012). However, investment in intercultural competence and services were largely abandoned during the early 2000s. The reason behind this change was that authorities feared that these services would hinder integration by undermining the need for ethnic minorities to integrate (Helberg-Proctor et al. 2017).

Although this shift to assimilationism has caused disaffection with multicultural policies at the national level, urban governments have not uncritically adopted the assimilationist discourse in policies. However, they have largely ceased to make specific policies to support minority groups (Poppelaars and Scholten 2008; Hoekstra 2015; Dekker and Van Breugel 2019). The case of Amsterdam, in particular, demonstrates the effect of the shift from policies targeting minorities to diversity-mainstreaming policies. Uitermark, Rossi, and Van Houtum (2005) show that policies targeting minorities had been replaced by a diversity-mainstreaming policy. The latter were oriented towards enhancing individual capabilities rather than addressing group problems and can be linked to the strategic positioning of Amsterdam as a diverse, cosmopolitan city. Under the city’s diversity-mainstreaming policy, ethnic self-organisations were only eligible for funding if their projects promoted integration into the wider urban society, e.g. through neighbourhood projects aimed at intercultural communication and integration. Uitermark, Rossi and Van Houtum found that the policy transition fuelled entrepreneurialism among well-established ethnic minority groups and disadvantaged new minority groups and groups with less social capital. In Rotterdam and The Hague, immigrants and ethnic minorities have, like their counterparts in the capital, similarly been ‘re-cast’ as citizens of ‘diverse cities’ with concomitant citizenship duties (Poppelaars and Scholten 2008; Hoekstra 2015; Dekker and Van Breugel 2019).

In the Netherlands as a whole, in the last fifteen years, a turn to localism has further fuelled the incidence of policies that call on the membership of local (urban) communities (De Boer and Van der Lans 2013). During this time, responsibilities for policymaking and policy implementation in the areas of youth care, employment, and social care for adults, including older people, have been transferred from the national government to local ones. ‘Localism’ is underpinned by the idea that needs for practical and more long-term forms of support in the mentioned areas are best met at the level of neighbourhoods, physically ‘close’ to (prospective) service users (Oldenhof, Postma, and Bal 2016). Many policies and implementation structures, therefore, in the first instance target neighbourhoods and neighbourhood residents. This generic, place-based approach fits with the emphasis on assimilationism and urban citizenship, which places the expectation on minorities to identify with the neighbourhood as a local imagined community. However, localism has been found to disadvantage minority groups, who have a larger relational distance to generic neighbourhood services (Carlsson and Pijpers, forthcoming; MacLeavy 2008). It is therefore questionable to what extent diversity-mainstreaming policies, which we find to be intertwined with ideas about localism and urban citizenship, will lead to better service provision for ethnic minority elders.

Diversity-mainstreaming policies through a crafting lens

There is a burgeoning literature within Urban Studies on local adaptation and resistance to diversity-mainstreaming policies, particularly those which pertain to integration issues (see e.g. Uitermark, Rossi, and Van Houtum 2005; Poppelaars and Scholten 2008; Careja 2019). However, few studies investigate the implications of diversity-mainstreaming on the provision of health and social care to minorities (for an exception see Brandhorst, Baldassar, and Wilding 2019). Despite the limited literature, our review of the diversity-mainstreaming research through the lens of crafting practices helped us to identify potential problems and possibilities caused by the implementation of diversity-mainstreaming policies in the health and social care domain.

Critics have argued that diversity policy obstructs, rather than furthers the social justice it purports to achieve (Ahmed and Swan 2006; Faist 2009). Since ‘diversity’ is a broad and vague term, diversity policies have been found to miss concrete guidelines for implementation (Van Breugel and Scholten 2017). For example, in Milan, Angelucci, Marzorati, and Barberis (2019) found that ‘diversity’ remained ill-defined in local policy documents, and that there was a lack of clear strategies and plans regarding the management of diversity. The reason why some scholars (e.g. Boccagni 2015; Dobusch 2017) are tentatively positive towards diversity-mainstreaming policies is because they believe that such policies can create categories that are less essentializing and more sensitive to different dimensions of inequality, including educational level and socioeconomic background (Scholten, Collett, and Petrovic 2016; Dobusch 2017). Ambrosini and Boccagni (2015), Schiller (2015) and Cianetti (2020) found that local governments can pragmatically adopt the rhetoric of mainstreaming policies to include various facets of diversity. As such, diversity mainstreaming policies might be able to grant the crafting space to better respond to citizens’ needs.

While ‘diversity’ provides room for interpretation by individual policy officers to adapt services to meet local citizen’s needs, Schiller (2017) cautions that overreliance on individual policy officers to implement diversity-mainstreaming policies can result in path dependency, with activities from previous, multicultural policies being continued rather than revised to fit the aims of diversity mainstreaming. In her study of local implementation of diversity-mainstreaming policy in Leeds, Amsterdam and Antwerp, Schiller (2017) found that policy officers that previously worked with multicultural target groups often took over the new, diversity-related policy themes. As a result, they were likely to continue with activities targeting ethnic groups rather than addressing a broader range of differences in accordance with the aim of diversity policies. To summarise, we find evidence in the literature that diversity-mainstreaming policies are plagued by implementation paradoxes. They leave much crafting space but too few crafting tools in the form of technical, institutional, and symbolic resources. Therefore, little direction is provided regarding how inequalities in access to and use of services should be addressed.

To date, there have been limited studies on how diversity-mainstreaming policies are implemented by frontline workers in health and social care. The studies that do exist point to a second implementation paradox inherent to diversity-mainstreaming policies: the vagueness of ‘diversity’ can inhibit concrete action to address inequalities linked to ethnicity and race. For example, Nieswand (2017) and De Koning and Ruijtenberg (2019) found that diversity-mainstreaming led to a ‘colour-blinding’ of care provision. As frontline workers attempted ‘not to see colour’, aspects of cultural and ethnic difference became unspeakable in conversations with and about families receiving care. Therefore, in this instance, diversity-mainstreaming undermined the ability of workers to reflect on issues connected to ethnicity. This is problematic since it hinders conversations about how inequities caused by race and ethnicity can be addressed. Theoretically, diversity-mainstreaming policies offer an opportunity to avoid culturalization and to instead respond to a range of differences influencing equality, such as socioeconomic background, gender and education (Boccagni 2015). In practice, diversity-mainstreaming might undermine investment in, and exchange of specific knowledge relating to cultural and ethnic diversity.

In the case of aged care for older migrants, the literature indicates that ethno-specific organisations are a source of local knowledge which is important to succsesfully reach out to and support older migrant populations in Australia and the Netherlands (Brandhorst, Baldassar, and Wilding 2019; Carlsson, Pijpers, and Van Melik 2020). In a study of aged care in Switzerland, whose population can be characterised as super-diverse, Ciobanu (2019) found that the resources to meet individual care needs of older migrants instead were generated within mainstream care facilities through dialogue with individual clients and their families. Although this individualised approach can be beneficial to individual clients it has disadvantages at the population level. Without formal structures in place, it becomes a question of luck whether an organisation can match staff and clients with similar migration backgrounds or language skills (Ciobanu 2019).

It is yet unclear how the switch to mainstreamed services in the Dutch context will influence care provision for ethnic minority elders. Like the Netherlands, Australia has experienced disaffection with multiculturalism. In the case of Australia, Brandhorst, Baldassar, and Wilding (2019) caution that ‘cost-reducing mainstreaming service approaches risk undermining the delivery of ethno-specific care' (2019, 14). It may thus be that the diversity, in turn, undermines investment in local knowledge and services which constitute key crafting tools to reach ethnic minority elders.

Research approach

To research how diversity-mainstreaming policies were implemented, we used a multiple case study design. We chose Nijmegen and The Hague since these cities represent, in the national context, a middle-sized (177 000 inhabitants) and a large (545 000 inhabitants) urban area with a high degree of ethnocultural, religious and linguistic diversity (Jennissen et al. 2018). However, we did not undertake a comparative study tracing similarities and differences back to these parameters. Rather, we wanted to research where and how crafting practices in these two municipalities converged and diverged, similar to previous studies on the local implementation of national diversity-mainstreaming policies (Schiller 2015; Nieswand 2017).

We followed developments concerning reaching out to ethnic minority elders first in Nijmegen (2017–2018) and thereafter in The Hague (2018–2019). We are aware that the population of ethnic minority elders is highly internally diverse in both cities, and not emphasising this diversity (enough) in academic publications can lead to an ‘Othering’ of older migrants and ethnic minorities (Torres 2006). We still chose to refer to ethnic minority elders as one population group, since a lack of care which is sensitive to culturally and linguistically diverse needs and preferences constitutes a barrier to access aged care for this population as a whole (Ahaddour, Van den Branden, and Broeckaert 2016; Chaouni Berdai, Smetcoren, and De Donder 2020).

We took an ethnographic approach to study ‘crafting practices’ as defined by Bannink, Bosselaar, and Trommel (2013). We used participant observation, semi-structured interviews and document analysis because these methods are suitable to expose knowledge about practices (Bueger and Gadinger 2018). We began each case study by conducting semi-structured interviews with policy officers who worked explicitly with ‘diversity’ or with ethnic minority elders. Through interviews we traced their connections to other actors, to gain a better grasp of the relevant services, organisations, and individuals, which we then studied through semi-structured interviews and/or participant observation. Tables 1 and 2 provide an overview of the fieldwork, detailing the different actors interviewed (44 in total) and the organisations and activities where we conducted participant observation (295 h in total).

Table 1. Overview of actors interviewed.

	The Hague	Nijmegen
Type of actor	Profession
Policy officers	Policy officer diversity (1); Policy officer older people and social support (1); Former policy advisor older people/current senior advisor mainstream residential care organisation (1)	Policy advisors (3); Contract manager (1)
Managers	Coordinator day care initiative 'Haags Ontmoeten' [The Hague Meets] (1); Manager minority-specific day and home care organisation (2); Manager umbrella organisation for social care organisations (1); Manager and trainer volunteer support organisation (1); Board member diversity mainstreaming network (1); Director diversity mainstreaming network (1); Course coordinator and teacher diversity mainstreaming network (1)	Coordinator of pool of intercultural advisors (1); Project leader municipal platform day care organisations (1); Manager minority-specific day and home care organisation (2); Coordinator neighbourhood information centre (1); Manager diversity and informal care social work organisations (1)
Frontline workers	Day care coordinators and activity leaders of minority-specific groups (3); Intercultural eldercare advisor (1); Eldercare advisor (6)	Day care coordinators and activity leaders of minority-specific groups (5); Intercultural eldercare advisor (1); Team leader social neighbourhood team (1); District nurse specialised in aged care (2); Manager information centres Nijmegen (1)
Other	Chairman older people’s city council (1)	Muslim chaplain (2)
	22	22

Total: 44.

Table 2. Overview of participant observation sites.

Nijmegen	Organisation	Nr. of observations	The Hague	Organisation	Nr. of observations
	Day care provider with multicultural/Islamic profile	27* 3 h		Day care provider with Hindustani group, part of ‘Haags Ontmoeten’	6*7 h
	Day care provider with Turkish profile	6*5 h
	Day care provider with Indonesian group	6*7 h		Day care provider with Chinese and Javanese groups	5*6 h
	Information and advice centre	8*2,5 uur		Volunteer support organisation	4 h
	Diversity café	5*3 h		Chinese association The Hague	2 h
	‘Netwerk 100’ Working group: Dementia and older migrants	4*3 h
	Expert group older migrants (facilitated by mainstream welfare organisation)	5*3 h		Diverse City	2 h
		215			80
Total		295 h

We included policy officers employed by the local governments since they occupy the lead role in shaping general diversity policies, policies for care and support, and the contracting of health and social care providers. We also attended meetings of Diverse City in The Hague, and the Diversity café, a soundboard group for older migrants and a network for professionals working with older migrants with dementia, all in Nijmegen. These networks and groups were of interest because they were platforms for exchanging knowledge about care and ethnic and cultural minorities. We also included providers of ethno-specific day care and professionals referred to as intercultural eldercare advisors since these services targeted ethnic minority elders. The term ‘intercultural’ points to the ability to navigate cultural difference (see footnote 1) and the eldercare advisor provided support to access care to minority elders directly and assisted other frontline workers with intercultural communication. The observations were carried out by the first author who actively participated in debates and working groups and volunteered at the day care centres. Interviews were conducted at the workplace of the interviewees. All interviews were transcribed.

Table 3 provides an overview of the analysed public documents that contained information about the development of local aged care provision relevant to the older people, ethnic and cultural minorities, ‘diversity’, and vulnerable groups. We selected documents from 2014 onwards as these were prepared with a view to a large-scale transition to localism in the Netherlands which took effect in January 2015.

Table 3. Overview of policy documents.

Nijmegen	Content of document	Year of publication
	Policy framework for the Social Support Act and the Youth Act 2015–2018	2014
	Response to proposal ‘Divers is Sterk’ [Diverse equals strong], with an overview of policies and practices with respect to diversity developed by care and welfare providers	2017a
	Progress report about social neighbourhood teams and information and advice centres	2017b
	Health agenda 2017–2020	2017d
	Two documents on funding of basic welfare infrastructure 2017–2020	2017c, 2018
The Hague
	Den Haag, Seniorvriendelijke Stad [Age-friendly city] 2015–2018 Action programme for policy	2015
	Ageing trend monitor The Hague	2017, 2018a
	Reply to motion 'Interculturalisatie van de gezondheidszorg' [Interculturalization of health care]	2018b
	Policy plan welfare infrastructure 2015–2016	2015

Fieldwork was conducted over two years and the analysis was carried out as an iterative process. We began by focusing on the impact of localism but found during fieldwork that assimilationism and the abandonment of target-group policies were equally pressing issues for stakeholders involved in care for ethnic minority elders in Nijmegen. As a result, fieldwork in The Hague and the subsequent analysis focused on the interaction between the policy trends of localism and diversity-mainstreaming in crafting practices. All interview transcripts, field notes and documents were coded using the software package ATLASti 8. We conducted analysis drawing on the principles of grounded theory (Charmaz 2014), by first conducting a round of descriptive coding. Thereafter, we discussed the meaning of the most grounded codes and identified interesting topics. These were further explored through a review of literature on localism and diversity-mainstreaming policies. The review was followed by a second round of axial coding.

Diversity-mainstreaming: limitations and scope for crafting responses to the care needs of ethnic minority elders

Our findings show that Nijmegen and The Hague adapted a diversity-mainstreaming discourse in local policies and implemented it through organisational networks, public debates, and, in the case of Nijmegen, contracting procedures. Apart from these initiatives, ethno-specific services like intercultural eldercare advisors, day care, home care and residential care were offered. Some of these services can be traced back to policies targeting ethnic minorities, whereas others were established after the turn to assimilationism had already occurred. The history and development of these services are further elaborated in the following sections. Table 4 provides an overview of diversity-mainstreaming activities and ethno-specific service provision.

Table 4. Overview of service provision.

City	Services targeting cultural, ethnic and linguistic minorities	Services centred on intercultural competence	Initiatives and organisations centred around notions of diversity
The Hague	Home care offered in different languages/multicultural profile; Day care for Indonesian, Chinese, Turkish, Moroccan, Hindustani, and multicultural groups; Residential care for Chinese, Dutch Indonesian, Malukan, Surinamese, Hindustani and multicultural groups; Co-housing for Chinese, Turkish, Surinamese, Surinamese-Creolean, Surinamese-Javanese, Hindustani, Antillean, Dutch-Indonesian and Moroccan groups	Intercultural eldercare advisors (Cantonese, Berber and Arabic, Turkish)	Divers Den Haag: Learning trajectory about super-diversity in the city; Debates and events around diversity-mainstreaming of organisations; Pep Den Haag: Volunteer trainings on diversity
Nijmegen	Home care offered in Turkish; Day care for Indonesian and Turkish groups; Meeting group for Chinese older people; Multicultural meeting group	Intercultural eldercare advisors (Berber and Arabic, Turkish); Meeting group for frontline workers in health and social care working with older migrants with dementia; Intercultural pool of expertise (volunteers assisting with linguistic and cultural interpretation)	Diversity café: Debates and events around diversity-mainstreaming of organisations

The mix of diversity-mainstreaming activities and ethno-specific services resembles findings from other studies of the implementation of diversity-mainstreaming at the urban level (e.g. Schiller 2015). However, this paper sheds new light on how this service mix was achieved. Our findings show that the mix of ethno-specific and diversity-mainstreaming was the result of deliberate crafting processes and reflected stakeholders’ ongoing practical concern with existing diversity among ethnic minority elders. The following sections detail how diversity-mainstreaming initiatives and ethno-specific services were crafted respectively. In particular, we pay attention to the crafting space and crafting tools provided by diversity-mainstreaming policies (or the lack thereof), and whether these facilitated or hindered local stakeholders to meet the care needs of ethnic minority elders.

Crafting diversity-mainstreaming policies and initiatives

Interpreting ‘Diversity’: from culturally sensitive to colour blind

Our analysis of municipal policy documents shows that ‘diversity’ was an often-used term when describing desirable outcomes within the policy domains of health and social care. However, the term eluded precise definitions and was differently interpreted in each municipality. In Nijmegen, ‘cultural sensitivity’ was used in tandem with ‘diversity’ in policy documents relevant to aged care from 2015 onwards. Policy officers used these terms both to encourage mainstream providers to be inclusive and to create space for ethno-specific services. To the latter end, the term ‘culturally sensitive working’ was included as a contracting criterion for all services. ‘Culturally specific providers and products’ (Nijmegen Municipality 2017a), which in this paper are referred to as ethno-specific services, were also mentioned as included in a broader strategy to meet diverse care needs and preferences in the provision of home and day care.

In Nijmegen, ethno-specific services were partly framed as a response to the care needs of vulnerable groups. For example, mental health issues of older migrants are identified in the health agenda for 2017–2020 Municipality of Nijmegen 2017b), and challenges to reach migrant family carers are mentioned in the policy for social support and youth Municipality of Nijmegen 2014). However, ethnic minorities were not only marked as ‘diversity-relevant’ (Dobusch 2017) because of specific vulnerabilities but also because of diverse preferences. A policy officer responsible for day-care provision in Nijmegen pointed out that the municipal strategy was to ‘provide something for every taste’; whether that was day care in the Turkish language or the provision of social groups for highly educated men. As such, policy formulation in Nijmegen allowed space for a variety of service provision in affirmation of diversity associated with different life experiences.

Because of its historically large migrant populations, many ethno-specific services targeting different minority groups existed in The Hague at the time of the study. The reason why they were still included was likely that the responsibility for contracting lied outside the responsibility of policy officers in the domain of older people and diversity. The contracting of ethno-specific services conflicted with the long-term policy aim of diversity-mainstreaming of all services. In our interview, the policy officer stressed that ethno-specific services had little political support and that the municipality wished that these services would disappear over time:

If we have any influence, then we do not support it financially [ethno-specific services] I also understand that you see initiatives that emerged long ago before this [diversity] was a topic. It would be logical that that knowledge can stream back into the broader health and social care network. (policy officer The Hague)

Nevertheless, the policy officer acknowledged the care needs of clients of ethno-specific organisations, and the expertise required to meet them:

You have a care home for Chinese residents here in the neighbourhood, and the care home staff definitely have a lot of knowledge and can provide quality care for that target group (I should not say target group). How they can provide good care, that is, of course, knowing that you can use if you want to work more inclusively. (policy officer The Hague)

While the policy officer highlighted the local knowledge within ethno-specific services as a key to inclusive service provision, she did not articulate how such knowledge might be transferred into regular services. The recognition of ethnic minority elders’ care needs paired with a lack of concrete plans for how these needs should be met without specific services can also be identified in policy documents. In a municipal report on older populations (Municipality of The Hague 2018a) older people ‘with a migrant background’ are reported to have a high risk of depression, low satisfaction with housing and relatively low use of institutional care. While older minorities are framed as a group subject to health inequalities, vulnerability is only described as ‘social, economic and health’ related in a municipal report on older populations (Municipality of The Hague 2018b, 20).

The abstract and individualised approach to difference and inequality reflects colour-blind approaches found in Dutch youth work (de Koning and Ruijtenberg 2019). In the report there were no recommendations to address inequalities experienced by ethnic minorities. The municipality of The Hague thus closely monitored ethnic minority groups without formulating approaches to address racial or ethnic inequalities. Westerveen and Adam (2019) use the term ‘monitoring the impact of doing nothing’ to describe a similar phenomenon at the national level in the Netherlands, where challenges concerning ethnic minorities are hardly mentioned in general policies while the performance of different ethnic minority groups on social indicators is regularly monitored. We thus find that the interpretation of the diversity-mainstreaming rhetoric limited the space to address health inequalities experienced by ethnic minority elders in The Hague.

An example of how diversity-mainstreaming policies limited the scope to address inequality can be found in the response to a motion to the local parliament to extend intercultural health care to address ethnic health inequalities. The mayor and the municipal executive board responded that health and social care professionals were ‘aware of the existence of all forms of diversity and act inclusively and sensitively’ (Municipality of The Hague 2018a, 2) and denied the need for more intercultural services. To summarise, we found, like Dobusch (2017), that the term ‘diversity’ was differently employed across municipalities. Local interpretations allowed for tailoring of services to ethnic minorities in Nijmegen but limited the scope for action in The Hague. This difference in interpretation might result in spatial inequality in terms of access to culturally sensitive service provision (Ciobanu 2019).

Is too much space for interpretation inhibiting action?

The vagueness of ‘diversity’ did not only make for uncertain outcomes in municipal policy formulation. It also made it difficult to set aims in terms of concrete outcomes of diversity-mainstreaming activities organised by the municipalities. Both municipalities had launched organisational networks, staff and volunteer training trajectories, public debates, and professional meeting groups on the topics of diversity and cultural sensitivity. Because ‘diversity’ was loosely defined, we found that it was difficult for policy officers and managers of the diversity-mainstreaming networks to stimulate organisations participating in the activities to take concrete action.

Diverse City, an organisational network led by experts, regularly put diversity ‘on the agenda’ via its debates and staff training. However, policy officers encountered resistance when they suggested that member organisations would commit to embedding ‘diversity-sensitivity’ in their quality frameworks:

At some point, I asked ‘Shall we focus more on access? Access to care is on the political agenda, and there is a concern with the question of how we improve access? Can’t we embrace this as Diverse City to show what older people really need?’ But that was not received very well over there. They did not want to single out [specific issues] and were more interested in showing that it is normal to look through a diversity lens. (former policy officer The Hague)

Because of the unwillingness of participating organisations and the organisers to undertake specific actions, the policy officer felt that the diversity network had a limited impact on ethnic inequity regarding access to care. This concern was shared by a senior advisor of an organisation supporting inclusive voluntary work, who worried that some member organisations of Diverse City considered diversity-sensitivity to be a ‘theoretical rather than practical’ issue. A board member of Diverse City agreed that some organisations failed to act but felt that participation in the network still triggered a continued discussion about diversity with the organisational boards. We encountered different interpretations among our interviewees of the long-term effect of the network. Overall, our findings confirm that the degree to which diversity-mainstreaming leads to concrete action hinges on the commitment of individual organisations (Tandé 2017).

Our study does not evaluate the impact of diversity-mainstreaming initiatives on access to aged care for minority elders. However, what we do find is that the diversity-mainstreaming initiatives can limit the discursive scope to undertake action to increase equity of access to aged care. The former policy officer, who generally was in favour of mainstreamed rather than ethno-specific care provision, pointed out the tension between the aims and the implementation of the diversity network:

You want to show that it is something very normal, it is very normal to be culturally sensitive. But at a certain point, it becomes so flat, that it is not much of anything anymore. You cannot even use the word ‘culture’ anymore. Then it becomes ‘diversity’. (former policy officer The Hague)

What this quote points out, is that ‘diversity’ can render difference unspeakable and thereby hinder actors to address social inequalities.

In contrast to findings on youth care (Nieswand 2017; de Koning and Ruijtenberg 2019) colour-blindness was not common in the practices of the interviewed frontline workers. However, the discourse of colour-blindness did influence the public debates regarding service provision for ethnic minority elders. In Nijmegen, we followed a diversity-mainstreaming activity called the Diversity café. The Diversity café was a public bi-monthly event for professionals in health and social care. At one of the events, the topic was how to ‘diversity-proof’ aged care, and representatives from mainstream and an ethno-specific organisation were invited to the discussion panel. In the debate, it was clear that despite the crafting space that the policies in Nijmegen provided, ethno-specific services remained politically sensitive. Representatives from the mainstream organisations defined diversity as a ‘space to be different but on an equal level’. They also stated that; ‘no one should choose MultiCare (an ethno-specific provider) because they don’t feel welcome elsewhere’, propagating for inclusive services (field notes October 2017). However, there was no mention of how mainstream organisations worked to make their activities inclusive for minority elders. To fit within the diversity-mainstreaming frame, the ethno-specific organisation argued that they sought to meet the client’s individual needs, particularly the need for care in the client’s language. However, there was little mention of positive needs of minority elders, such as belonging and recognition.

The examples from Diverse City and the Diversity café highlight the tightrope that the diversity-mainstreaming discourse asks organisations, frontline workers, and municipalities to walk when crafting practices. One might expect that the normalisation of (cultural) diversity would lead to service provision that accommodates a broader range of cultural preferences and linguistic needs. Instead, the diversity-mainstreaming discourse in The Hague obstructed actions targeting inequality of access caused by linguistic or cultural diversity. In Nijmegen, the need for belonging and meaningful activities went unrecognised in discussions of diversity-proof care. Instead, tailored services were justified due to the poor Dutch language skills of older labour migrants, an argumentation which reoccurred in our interviews with all actors. Our findings thus confirm the paradox identified in the literature review of ‘diversity’: it simultaneously provides and limits the scope for action. In addition, our study highlights how, in the case of aged care, this implementation paradox can cause actors to fail to recognise the full spectrum of care needs of ethnic minority elders, an issue which resurfaces in the crafting of ethno-specific services.

Crafting ethno-specific services within a diversity-mainstreaming discourse

Diversity-relevant care needs?

The existence of ethno-specific day and home care cannot be traced back to a bygone multicultural policy area in neither Nijmegen nor The Hague. Indeed, the ethno-specific care organisations in our research (Carlsson, Pijpers, and Van Melik 2020) and also in the research of Kremer (2019) which focuses on The Hague, have only existed for a decade. These organisations were established by local ethnic minority (notably Dutch-Turkish) entrepreneurs, with a professional background in health care, who wanted to provide appropriate care for ageing community members. Some of them had also been active in local politics or ethnic minority self-organisations and were aware that they needed to position themselves as relevant in a changing policy landscape. In interviews with two managers of such organisations, both stated that they had had to negotiate the necessity of their existence. The manager of one of the ethno-specific day and home care organisations explained that:

Along the way we have made our point to several institutions, one of them the municipality, that for some target groups you can’t just assume that ‘yes, your needs will be met by any day-care, but no, that requires specific attention and knowledge'. (manager ethno-specific day and home care organization with multicultural profile Nijmegen)

The manager of an ethno-specific care organisation in The Hague echoed the experiences of managers in Nijmegen. She told us that her organisation was met with suspicion in the beginning. It was only after some time that the municipality recognised that ‘you are really good at reaching the target groups that we don’t know how to reach’. The expertise and skills within these organisations in reaching minority elders was an important reason as to why they were included in the provision structure (policy officer Nijmegen).

Even though some of these organisations effectively provide care to clients with the same ethnic background, they were marketed in a more general way, e.g. as having expertise in a client’s language and culture. As a result, they were known to be culturally specific rather than ethno-specific organisations. A quote from a manager in Nijmegen highlights how crafting ethno-specific practices required them to frame their organisation within a diversity-mainstreamed discourse:

We are doing target group policy now, but it should not be a structural process. In a longer-term perspective, in 10–15 years, it must lead to a regular provision, that is an ideal that we have (…) we mirror society, that is our vision. (manager ethno-specific day and home care organization with multicultural profile, Nijmegen)

The framing of ethno-specific care as a temporal solution for older people with limited Dutch language ability was echoed by policy officers too (policy officer Nijmegen, September 2017). In crafting ethno-specific care practices, both health care managers and policy officers drew on an assimilationist framing, which assumes that language barriers are the only reason for ethno-specific meeting services and that such barriers, in all likelihood, will disappear as most second-generation labour migrants speak better Dutch than their parents. No reference was made to emerging ethnic and cultural minorities, such as late-in-life migrants coming through family-reunification or as refugees.

Frontline workers in ethno-specific day-care also referred to linguistic needs when framing the need for their services. A coordinator of day-care activities pointed out how the weak language skills made the Chinese group dependent on ethno-specific services. Interestingly, this argument was also used by a frontline worker who worked with a Hindustani day-care group where most clients spoke fluent Dutch. Day care and meeting activities are known to facilitate a sense of belonging, create a space free from exclusion, and to lower the threshold to other, mainstream services (Patzelt 2017; Carlsson, Pijpers, and Van Melik 2020). Although a sense of belonging and the accommodation of different preferences were mentioned both by a coordinator of day care in Nijmegen and by the manager of the ethno-specific home care organisation in The Hague, these arguments did not appear in the studied policy documents or the observed public debates. Ethnic minority elders were thus primarily framed as diversity-relevant on the basis of vulnerability/special needs, rather than in affirmation of a diverse set of preferences and lifestyles.

Local knowledge

Bannink, Bosselaar, and Trommel (2013) argue that in a localised policy context, the knowledge and expertise of the local crafting community constitute a necessary tool to craft an appropriate response to local crafting challenges. In our study, all actors considered local knowledge and ties with local minority communities contained in ethno-specific services to be a key crafting tool. In what follows, we will unpack how the framing of these services might undermine the role of local knowledge and networks as crafting tools, and how the different actors responded to this paradox.

Our first example of how actors rely on local knowledge to reach out to ethnic minorities concerns the work of intercultural eldercare advisors. In both Nijmegen and The Hague, frontline workers with intercultural competence, and who speak the languages of the largest minorities, provided eldercare advise across the city (interviews intercultural eldercare advisors Nijmegen 2017, The Hague 2019). These intercultural eldercare advisors were available for appointments and walk-ins at several information and advice centres in neighbourhoods with a high proportion of minorities. Also, intercultural eldercare advisors were available to support generalist frontline workers when they struggled to communicate with clients. Our earlier research shows that they play an important role in lowering the threshold to information and advice centres as well as other forms of aged care services for minority elders (Pijpers and Carlsson 2018).

In The Hague, intercultural eldercare advice received less support than in Nijmegen, but the service was still described as part of the strategy to reach older minorities in policy documents (Municipality of The Hague 2018b). Paradoxically, a manager of a welfare provider in The Hague argued that while the policy is to ‘not focus on minority groups’, this particular intercultural service, which was a remnant from the multicultural policy era (Helberg-Proctor et al. 2017) had gained importance with the growth of the population of older migrants. While acknowledging the high demand for intercultural eldercare advisors, the manager expressed unease about the conflict between diversity-mainstreaming policy and continued multicultural service provision, similar to the findings obtained by Schiller (2015).

In Nijmegen, the introduction of intercultural eldercare advisors constituted a more recent response to the lack of success of social workers organised in multidisciplinary ‘social neighbourhood teams’³ in reaching minority populations. A policy officer in Nijmegen explained that:

When we didn’t have target groups anymore and were in the phase of social neighbourhood teams and inclusion and person-centred care, we thought that all would be solved within that vision, but at a certain point we realized that it was not enough. (policy officer Nijmegen)

We found that intercultural eldercare advisors played an important role not only in direct work with minority elders but also in consulting generalist social workers. An eldercare advisor in The Hague explained that intercultural eldercare advisors were called in both to mediate with clients, and to assist them and others in connecting to ‘hard to reach’ communities:

We have a Turkish, Moroccan and Chinese eldercare advisor who is for those target groups and works The Hague-wide. And indeed, there are cases when we notice that they let me in, but they do not tell me everything and they are not at ease. Then you ask yourself, gosh, is something else possible, then we get in touch [with the intercultural eldercare advisor] and ask, hey, can you get involved? But also, in situations when we notice that we cannot make enough contact with a certain target group. (intercultural eldercare advisor The Hague)

From this description, we see that intercultural eldercare advisors facilitate connections between clients and mainstream providers, and between communities and health and social care provision. Intercultural care advisors framed themselves as a source of expertise regarding how to connect and mediate between minority elders and mainstream providers. Similar to the managers of ethno-specific care organisations, intercultural eldercare advisors felt the need to justify their roles in the current policy context:

I agree that if you only provide support in the client’s language, then you do not support independence, then they become dependent. But, if you come to good agreements; we are going to stimulate these people to become independent (…) then you have to make good agreements with the policy officer and the municipality, like, hey I give money, subsidies, not only to solve problems for Chinese people. But, to solve the problem together with the Chinese, and to stimulate that they can solve the problems independently in the long term, or, come with their issues themselves to Dutch organizations. (intercultural eldercare advisor The Hague)

The above quote illustrates how the intercultural eldercare advisors engage in crafting practices by arguing for the need for their services and framing them in a way that fits the diversity-mainstreaming framework. Although most frontline workers in regular services mentioned intercultural eldercare advisors as a source of expertise that they relied on to reach out to ethnic minority elders, there were only two and three advisors in Nijmegen and The Hague, respectively. Several of them struggled to manage the client load. The limited availability of intercultural eldercare advisors carried the risk that not all citizens receive the support they need to access care and, secondly, that intercultural eldercare advisors become overburdened. Since the population of older ethnic minorities is growing and diversifying in both cities, these problems are unlikely to diminish.

Conclusion and discussion

This paper investigated how diversity-mainstreaming policies in aged and social care providers may affect the scope for local policymakers and health, aged and social care managers and frontline workers to address the care needs of ethnic minority elders. The existing literature concerned with older migrants and/or ethnic minority elders has, with few exceptions (Bolzman et al. 2004; Ciobanu 2019), not yet drawn connections between policies relevant to older migrants/ethnic minority populations and policy implementation, particularly at the municipal level of aged care provision. As such, our study contributes to close this knowledge gap and responds to a call in the field for research to focus on how policymakers and practitioners can better meet the needs of minority elders (Torres 2018).

In addition to informing research on aged care for ethnic minorities, the paper contributes to scientific debates on how diversity-mainstreaming is implemented at the municipal level. In the Urban Studies literature on national and local integration policies, it is often assumed that partial implementation of diversity-mainstreaming policies reflects local pragmatism and/or friction between local and national policy (Schiller 2015). By applying analytical concepts from Public Administration, this paper provides further insight into the process of implementing of diversity-mainstreaming policies at the municipal level. We found that diversity-mainstreaming policies allowed local stakeholders to craft a mix of diversity-mainstreaming and ethno-specific services in response to ethnic minority elders, care needs. Considering the existing literature on older ethnic minorities’ use of care and services, continued provision of some ethno-specific services paired with a call for diversity-sensitivity within all services can be considered a positive development. However, we also found that diversity-mainstreaming policies were riddled by two related implementation paradoxes which impaired their ability to facilitate inclusive services, particularly in a long-term perspective.

Because of vagueness of terms, the ‘crafting space’ i.e. political empowerment that diversity-mainstreaming policies grant highly depends on their local interpretation. Therefore, we found ‘diversity’ to both inhibit and enable concrete action. When the interpretation of ‘diversity’ did provide crafting space, we encountered a second implementation paradox caused by the connection between diversity-mainstreaming policies and assimilationist assumptions. To craft services in response to the care needs of ethnic minority elders, we found that stakeholders found it necessary to frame ethnic minority elders as deserving of specific services primarily because of the problems they were assumed to be facing (Torres 2006), such as a lack of Dutch language skills. Underpinned by assimilationist assumptions, these services were framed as temporary solutions, rather than responses to long-term shifts in the ageing population. This was despite both the persistent demands for these services, and the literature showing that culturally appropriate services facilitate feelings of belonging and meet social needs, and facilitate care navigation (Ahaddour, Van den Branden, and Broeckaert 2016; Carlsson, Pijpers, and Van Melik 2020). We therefore argue that even when diversity-mainstreaming policies provide crafting space to meet current care needs, the assimilationist framing that the diversity discourse elicits, leads to the withdrawal of investment in ethno-specific services and intercultural expertise which represent local knowledge and networks. As a consequence, diversity-mainstreaming policies undermine the crafting tools necessary to achieve the inclusion it purports to achieve, particularly in the long term.

Older populations in Europe are becoming increasingly culturally and linguistically diverse (Ciobanu, Fokkema, and Nedelcu 2017; Brandhorst, Baldassar, and Wilding 2019). To address existing health inequalities and to make future care provision more inclusive, we argue that ethnic minority care needs warrant a more positive framing in local policy discourse and implementation. The migration background of ethnic minority elders can be understood as a source of meaning-making, community involvement, and quality of life, to be supported by a combined offer of ethno-specific, intercultural, and mainstream services. We suggest that policymakers take a more positive approach to the diverse cultural, linguistic, and ethnic preferences of older people. Affirming differences, including but not limited to ethnic background, constitute a more future-oriented governance response to the growing diversity of local ageing populations.

Acknowledgements

Our thanks to all interviewees and organisations who gave of their time and expertise to this research project. We are also indebted to members of ENIEC, the European Network of Intercultural Elderly Care, for assisting us with gaining access to the field. Many thanks to Dr Rianne van Melik, Dr Laura Dobusch, participants of the Gender and Diversity PhD seminar at Radboud University and Dr Kai Whiting for their comments and suggestions on earlier versions of this manuscript. We are also grateful to the two peer reviewers for the constructive and helpful feedback which significantly improved the paper.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Correction Statement

This article has been republished with minor changes. These changes do not impact the academic content of the article.

Additional information

Funding

This work was supported by the Netherlands Scientific Organisation (NWO) [grant number 452-16-008].

Notes

1 In health and social care in the Netherlands, ‘intercultural’ is a term indicating responsiveness to cultural difference in understandings of sickness, health and care needs (see Mladovsky et al. 2012).

2 ‘Localism’ refers to the trend of decentralising responsibilities for health and social care services to municipalities and the organisation of services within neighbourhood structures.

3 For a more detailed account of the role and composition of social neighbourhood teams in the Netherlands see Van Arum and Van den Enden (2018) and van Zijl et al. (2019).