Marie Østergaard Møller Associate Professor, PhD. TARGETING HEALTH CARE THROUGH PREVENTIVE WORK - A study of the impact of social distance on professionals’

Marie Østergaard MøllerAssociate Professor, PhD.

TARGETING HEALTH CARE THROUGH PREVENTIVE WORK- A study of the impact of social distance on professionals’ judgments of children and families’ need of health improvements.

Introduction

It is widely recognized that health care is in a state of crisis. Increased public spending and a decline in support towards poor-resourced people dominate as standard explanations. In Denmark, a welfare state with universal health care, the crisis has led to an adjustment of the universal health care access. The political response has been to target health services to ‘those in need of special care’ through a more intense focus on prevention. The idea is to prevent illness instead of curing it. I study the impact of these new rules on the frontline level where home nurses, pedagogues and teachers interact with children and their families. A study shows that frontline workers think differently about whom to prevent from what, when and why. The degree of social distance as well as professional norms explain part of the variation in worries towards children and families, but the impact of collective orientation, tolerance and aversion remain unclear.

Policy problem

”Most children in Denmark grow up in good and secure environments. They have parents, who support them throughout their childhood. They get emotional support and care. Everyday life is in control. The children learn how to become independent individuals and responsible citizens. They have a good childhood.

However, some children are not so lucky. They do not get the necessary support from home. There is not enough care. Everyday life is not in control. There are no boundaries. Maybe because parents are fighting their own problems, overshadowing the problems of their children. Maybe the parents do not have the necessary resources to raise and support their child.

Many of these children growing up under such difficult circumstances, manage to cope anyway. The outcome is not given beforehand. But these children have an enhanced risk of developing problems, reducing their chances of a good life.”

The Danish Government, Equal Oppertunities, 2007

www.categorization.dk


Theoretical approach:

Professionals’ judgments are based on different sources of criteria for judging such as formal rules (health Law), doxa (shared organizational knowledge), policy preferences, normality perceptions, professional knowledge (skills and professional identity) and habitus.

Data and design:

Interviews with 58 Danish home nurses, pedagogues and teachers who interact with children in 8 school districts within 4 municipalities.The interviews are designed to facilitate both interpretive analyses and systematic testing of hypothesis by using vignettes varying with respect to a child’s social characteristics.

Hypothesis:

Preventive reasoning demands professionals to react on ‘hunches’ of deviance, because no symptoms of health need are (yet) present. Hence, social categories of deviance such as ‘social distance’ is likely to influence their judgments of children and families’ need of health improvement.

Main results of professionals reactions towards an increase in social distance represented in

vignettes:

Impact No impact

Home nurses (16)

10 6

Pedagogues (20)

12 8

Teachers (22)

14 8

“The analysis suggests that professionals

intervene with more corrections of social

normality or lifestyles in the cases of social

distance”


Impact of social distance on professionals’ worry for children and families:

SOCIAL DISTANCE, WORRIES AND INTERVENTIONS- Professionals’ reactions to the presented vignettes in terms of judgments of children and families’ need of health improvements.

Case with similar social background (middleclass)

Case with dissimilar social background / social distance

(upper / lower class)

IP

Worried?

Suggested intervention

Class

Worried?


Teachers

TA01 (+)

Talk to the child and talk to the parents about the problems in behaviourOrganize play groups (in school and at home), talk to other parents about integration of the childGive him extra attention when teaching (e.g. easier tasks, extra help, special teaching class, test math skills)Give advice on learning activities at homeGive advice on social networks / relations, home work routines, free time activitiesTalk about TV-habits (perhaps on parent class meeting)

Lower

(+)

Talk to the child and talk to the parents about the problems in behaviourDiscuss the child with colleaguesGive him extra attention when teaching (e.g. motivate his reading, extra help, extra teaching)Give advice on parenting (discipline, responsibilities at home, conflicts at home)Give advice on home work routines, incite participation in school’s home work cafe

TA03 (+) (+)

TA06 + (+)

TB09 (+) -

TC12 (+) +

TC14 (+) +

TC15 (+) +

TC17 - (+)

TD20

(+) (+)

TD21

- -

TA02 (+)

Upper

+

Talk to the child and talk to the parents about the problems in behaviourGive him extra attention when teaching (e.g. easier tasks, extra help, extra teaching)Work with social relations in the classGive advice on home work routines, incite participation in school’s home work caféGive advice on discipline (important to make demands)

TA04 (+) +

TA05 (+) +

TB07 (+) +

TB08 (+) +

TB10 (+) (+)

TB11 (+) (+)

TC13 - (+)

TC16 (+) (+)

TD18

(+) (+)

TD19

(+) -

TD22

(+) +




IP

Worried?

Suggested intervetion

Class

Worried?


Home nurses

NA02

(+)

Offer a second visit or call the family again to check up on them, offer family counselling. Incite participation in “mothers group”.Weight / screen / test the child (and the mother).Give advice on breastfeeding, sleeping-patterns, how to relax, the new role as parents, and how to handle daily routines.Establish help through own network (family), and help parents share work.

Lower

(+)

Offer a second visit, offer video-observation-counselling, discuss the case with other professionals (social worker).Incite participation in mothers group.Weight / screen / test the child (and the mother). Give advice on breastfeeding, how to “read” the child’s signals, daily routines, how to relax and “shutting of the TV”.Establish help through own network (family).

NA04

(+) +

NB05

(+) (+)

NB07

(+) +

NC09

(+) +

NC11

- (+)

NC12

- +

ND14

- +

NA01

(+)

Upper

(+)

Offer a second visit.Weight / screen / test the child (and possibly the mother).Give advice on breastfeeding and how to relax, not exercising all the time.(Not necessarily incite participation in mothers group).

NA03

(+) +

NB06

(+) (+)

NB08

- (+)

NC10

- (+)

ND13

(+) (+)

ND15

- (+)

ND16

(+) (+)




IP

Worried?

Suggested intervetion

Class

Worried?


Pedagogues

PA01 (+)

Talk to the child and parents (to find out more). Keep an eye in him. Offer physiotherapist / motor skill trainingDiscuss on staff meeting. Help child adjust to the day care centre, and relate to other childrenObserve behaviour systematicallyGive advice on sport-activities Advice parents to seek anonymous help/counsellingOrganize play groups to facilitate friendships Try to facilitate contact with other familiesIncite the parents to invite children with them home to play

Lower

+

Talk to the parents (they should understand problem)Offer language therapist / language training / concentration training. Test language skillsDiscuss child on staff meeting, with other professionalsObserve behaviour systematicallyMake “action plan” Help child relate to other children, and help him get integrated in activities (follow him / sit next to him in activities)Incite parents to invite children home to playGive advice on how to drop-off child in the morning

PA03 (+)

+

PB08 (+)

+

PB09 (+)

+

PC10 (+)

+

PC12 (+)

(+)

PC13 (+)

+

PC15 (+)

+

PD16 -

-

PD18 +

+

PA02 (+)

Upper

(+)

Talk to parentsOffer language therapist / language training / motor skill training. Test language skillsDiscuss the child on a staff meeting Help child relate to other children, and help him get integrated in activities (relate to him / “open him op”)Give advice on how to train language at home (read to the child, food)Give advice on how to drop-off child in the morning (make clear arrangements)Discuss lunch-arrangementOrganize play groups to facilitate friendships

PA04 (+)

+

PB05 (+)

(+)

PB06 (+)

(+)

PB07 (+)

-

PC11 -

-

PC14 -

(+)

PD17 -

-

PD19 (+)

+

PD20 -

(+)

I start to worry if there are twenty-five candles and the apples are lying in order all facing the same direction in the bowl. If it’s just too orderly. That does not make me safe. It’s just too much control. And then my alarm bells start ringing (Home nurse, NC11).

I had a boy once, who really did not fit in. He didn’t have any support from home, his father was not really there, and the mother was dyslexic, and not really interested. She made sure, that he had his fourteen yoghurts with him every day for lunch so he could get his sugar rush. He would come to school, smelling, not haven taken a bath for a long time […] and he just had a hard time in school, because he couldn’t find any friends. (Teacher, TB09).

She always comes five minutes before closing time […] Running with the stroller … and well she is actually at home all day. So it has to do with, when you pick up your child in the day-care, then you go give your child a hug, right? And things like that. She doesn’t do that. She just picks up their stuff and says: “now we have to go home” (Pedagogue, PB08).

Many professionals spontaneously makes the distinction between real or strong worries and minor worries or “keeping-an-eye-on-things”, giving the opportunity to use this distinction (indicated as (+) and + in the tables). An increase in worry is marked with dark blue and the same degree of worries is marked with light blue


No increase in worries: Professionals don’t increase their worry with increased social distance when they compare children’s problems to broader social context beyond the concrete workplace, because in these cases children’s perceived deviance is never associated with their own version of ‘health’ and ‘good manners’.

Increase in worries: Professionals increase their worry with increased social distance when they compare children’s problems to a narrow social social context for example the concrete workplace, because in these cases the children’s perceived deviance is explicitly associated to how they personally practice health and ‘good manners’.

The analysis do seem to give some support to the expectations of an impact of social distance on both the degree of worrying and on the tendency to intervene with corrections directed at lifestyles and social norms/normality. However, there are also indications as to other factors being important, supporting the need for further analysis of, in particular, why some professionals’ resist increasing their worry about children when they are exposed to social distance. Out of the 58 interviews, 22 did not increase their worry as social distance increased in the stories (vignettes) and in 4 interviews worries even decreased. Why?

Resistance to social distance can be interpreted as a tolerance towards difference.The relation between the professional’s moral agency and the child’s problem determines which social context the child is associated to. The symbolic boundary drawing used by professionals to identify themselves from different kinds of groups, communities and society in general contributes to the interpretation of the child as well as of difference in general.

The power of social context Further questions and analyses

Documents

Marie Østergaard Møller Associate Professor, PhD. TARGETING HEALTH CARE THROUGH PREVENTIVE WORK - A study of the impact of social distance on professionals’