Positionality and reflections on the research

Acknowledging the constructed character of knowledge and reality and my responsibility as a researcher and hence, an agent of construction, I consider important to reflect on my position through the research process and the normative values and experiences that inform the current work.

A short biographical note.

The way I understand myself and my social location involves the categories of a European, white, Greek, young, healthy, lesbian cis-woman. I grew up in Greece as a second- generation migrant, born to ethnically Greek parents but themselves born and raised in Turkey, and I have now reached the point of concluding my Phd at a highly ranked UK university. Due to my migration background and jus sanguinis citizenship regime in Greece, I was considered a Turkish citizen until the age of twenty-one. I have also a working-class background and childhood memories of poverty, while I am the first person in my extended family, who completed secondary education and entered university; thanks to the (currently threatened) Greek public education system. Seven years ago, I left Greece pushed by the economic crisis and the devastating unemployment rates that particularly hit educated women. I completed my post-graduate studies based on funding that came exclusively from scholarships and while working part-time for most period.

I first became conscious of my migration background and location at the age of five, when my parents had to register me at school. That process involved a series of stressful bureaucratic procedures, and my first visit to a police station, where I was registered as a migrant. At the age of approximately twenty-one, I acquired Greek citizenship and passport through naturalization. Through the multiple visits at the Greek migration services, I realised how waiting-times and treatment by civil servants was subject to the extent that a foreigner could pass as a Greek. Although it now makes me feel awkward, I remember me using my Greek looks and behavioral code to my benefit, in order to skip long queues of people who were looking less Greek than me. Later, those experiences fuelled my interest in the topic of migration and motivated me to engage with advocacy work in relation to migrant communities in Greece. Just before my thirties, I found myself a first-generation migrant this time, navigating the Dutch culture and bureaucracy, and studying at a prestigious university; things I would probably not have been able to do without my Greek passport. Until nowadays, in the UK, I identify as a migrant and not a foreign student, because there are reasons forcing me to stay away from Greece. The lack of job opportunities for highly educated women and the widely spread conservatism, sexism and homophobia in the Greek society are among them.

As emerges from this brief life-account, I occupy a social position that combines multiple privileges and disadvantages, and this has been accompanied by a fluctuating and long-lasting feeling of not belonging; or to put it more accurately the feeling of not-exactly-belonging across different contexts, including academic environments. Simultaneously, it comes together with an awareness that multiple classification systems present in practice and discourse have shaped together my life experience and that social categories are fluid, changing, visible or invisible. This life experience has been the reason why intersectionality theory resonates so much with the way I understand the world and my position in it, and I can confidently say, after completing this PhD thesis, that it fuelled my motivation to engage with this theory and its application in health inequalities research.

Challenges.

Working with intersectionality has not been an easy endeavour. My encounter with literature on intersectionality theory and research brought up a series of challenges from very early on. The first tension point was relevant with the fact that being myself a white woman, I got engaged with a theory developed through the life experience, scholarship and activism of Black women and women of colour. This posed questions regarding the appropriation of

intersectionality as a theoretical tool produced by socially oppressed subjects and the "whitening" of intersectionality (Bilge, 2013: 412). Following from this, the second point of tension concerned the importance of Black women as the epicentre of intersectionality research (Nash, 2008). I soon found myself reflecting on whether it was legitimate to use intersectionality theory, if I was going to study health inequalities that do not exclusively concern Black women or women of colour. Finally, having been trained in quantitative social sciences research, and working within a medical sociology stream that is predominantly focused on quantitative methods, I questioned the extent that I should, or even could, use a theoretical framework that has been predominantly associated with qualitative research and it has been often described as contradicting to the positivist underpinnings that are common in quantitative research (Bauer, 2014; Bowleg, 2008; Hancock, 2013).

The way I have responded to these challenges can be traced across the thesis, but I would like to summarise some important points. As many intersectional scholars have stressed, the contribution of intersectional research is the emergence and exploration of new questions stemming from the very position of "outsiders-within" (Collins, 1986) and are directly informed by a social justice agenda (Collins & Bilge, 2016; Schulz & Mullings 2006; Weber & Parra-Medina, 2003). As my short biographical note indicates, my intersectional social position and my experience as a marginalised subject in terms of gender, sexuality, class and migration background is the reason I embrace the status of an "outsider-within" in academia (but also outside of it), as well as the reason I aimed my PhD research to be informed by but also promoting a social justice agenda. From this position, I got engaged with the notion of health as a political concept and a human right, and I interrogated the direct link between health inequalities and social injustice and power imbalance. It must be said that looking myself as a researcher from an intersectionality lens allowed me to acknowledge my power to raise innovative and crucial questions regarding the study of health inequalities and at the same time, intersectionality seemed the appropriate theoretical framework for contextualizing my research within a social justice agenda.

Hence, though not a Black woman myself, I decided that my position and intentions allowed me to engage with intersectionality theory. Further, while critically reflecting on issues of theory appropriation and the centrality of Black women in intersectional research, I have consciously tried to engage with intersectionality in a way that highlights its theoretical significance (Bilge, 2013; Collins & Bilge, 2016). Shifting away from using intersectionality as a lens used to describe the experience of racialized women (Bilge, 2013; Nash, 2008), I employed it as an analytical tool for the understanding of health inequalities as the result of

social stratification. This is also reflected in my citation practices, where the theoretical work of Black women scholars and activists is prominent. In the same line, though not particularly focused on Black women, the significance of race and its intersections with gender and other social categories has been stressed throughout the whole thesis.

Finally, regarding the relevance of quantitative research methods, Ι built on arguments suggesting that what makes a research intersectional is its embeddedness within a social justice agenda in particular social, political, historical and cultural contexts (Bowleg, 2008; Collins & Bilge, 2016; Yuval-Davis, 2015), rather than the qualitative or quantitative methodology. Moreover, drawing on social constructionism that highlights the constructed character of social categories without disregarding their material consequences, I decided instead of taking an a priori fixed position (e.g. not using quantitative methods) to integrate this tension point as an integral part of my research. Hence, the challenges that emerge when intersectionality is applied in empirical health inequalities research (Bauer, 2014; Bowleg, 2008), including those specific to quantitative designs, are discussed in chapter four (i.e. the suggested analytical framework), and feed into concrete suggestions for a future research agenda. Further, I adopted a multi-method design that includes a quantitative and a qualitative case study, in order to explore the applicability and effectiveness of those suggestions.

A multi-method design.

At this section, I would like to briefly discuss the choice of the particular research design and the selection of the presented case studies. The current thesis is the outcome of a four-year project that started from a broad question regarding the implications of intersectionality for health inequalities research. The development of the suggested intersectionality and institutionally informed analytical framework presented in chapter four was the first stage of my Phd research. This framework in turn fuelled the research questions and the empirical studies that are presented in chapters five and six.

Aiming for a situated intersectional analysis (Yuval-Davis, 2015), and in line with the social constructionist underpinnings of my research, the development of the framework first involved a consideration of the social categories that are salient and relevant with social stratification in Europe, and hence, with the production of social inequalities in health. In the previous chapter, I explained the relevance of socio-economic position and gender. My particular focus on migration as a salient category for the understanding of health inequalities in Europe emerged from the thorough consideration of the socio-political and historic particularities of the specific context. However, my migration background, my previous studies

in the field as well as my previous experience in advocacy work related to migrant communities, have made me particularly conscious of and interested in studying the significance of migration as a social determinant of health (Castañeda et al., 2015) intersecting with other dimensions of social positioning (i.e. gender and socio-economic position). In the following chapter, I elaborate on this and I also discuss the urgency to focus on migration as a separate but intersecting category affecting life experience and health, and to disentangle it from the categories of ethnicity and race, while studying the ways it informs them and it is informed by them in the European context.

Further, the development of the framework involved the suggestion of an updated health inequalities research agenda posing innovative questions and bearing significant methodological implications for quantitative and qualitative designs. To demonstrate the applicability of this framework, and to illustrate how intersectionality is relevant with health inequalities research overall, I decided to adopt a multi-method design. Hence, in chapter five, I examine migration related health inequalities in Europe employing a quantitative multilevel multi-group analysis and interaction terms to operationalize the intersection between categories of gender, occupational status, migration and generation status and to account for their differential salience and impact across national contexts in line with Scott and Siltanen (2017) and Evans et al. (2018). This case demonstrates that we can use available statistical methods in order to study the material consequences of intersectional social positioning on individuals' health, and that conducting intersectionality informed quantitative research enables us to document the multiple relationships of health inequalities operating in the European context and not captured by mainstream studies.

Further, in chapter six, I conduct an intersectional qualitative analysis of the health- related response to refugees and migrants at the Greek borders as it evolved from the summer of 2015 until the summer of 2018 at the Greek borders. Employing a situated intersectionality approach, instead of focusing a priori on a specific group located at the intersection of specific categories (e.g. refugee women), I start my analysis by exploring which categories emerge as relevant to health inequalities in the specific context (Anthias, 2013), and I examine which intersections relate with increased exposure to health risk and damage for refugees and migrants. I conduct my analysis building upon the principles of intersectionality as a paradigm as suggested by Collins & Bilge (2016) as well as on the IBPA framework suggested by Hankivsky (2012). This case demonstrates how intersectionality informed qualitative research is effective in bringing to light the particular situation of multiply marginalized subjects who

are often ignored within mainstream health inequalities research, and how the interplay between macro-, meso-, and micro level factors produces vertical but also horizontal health inequalities.

Although both cases engage with the intersecting impact of migration on health and health inequalities, they focus on entirely different groups of people. Moreover, although in both cases the broader context is Europe, the actual study context differs between the two cases. This way, I aimed to illustrate how adopting an intersectional approach involves challenges that concern the whole research process regardless of the actual design but at the same time there are limitations particular to the methods chosen each time. Further, I attempted to make explicit how migration involves a series of other categories (i.e. generation status, legal status, race, ethnicity) and that it is its intersection with those categories that renders certain individuals and groups more vulnerable than others. Importantly, I attempted to highlight how intersectionality encourages us to insist on adopting an explorative approach in order to unveil relationships of health inequalities that are often ignored and the particular situation of groups who are privileged in certain hierarchies and disadvantaged in others. The strengths and limitations of each study are discussed in the relevant chapters but also in the final discussion chapter, in which I reflect upon the applicability of the suggested framework.

Chapter Four

Understanding the Micro and Macro Politics of Health: Inequalities, Intersectionality & Institutions - a Research Agenda