Meeting the Needs of the Social Care and Health Care Workforce: Can a Duck Sleep with a Hippopotamus?

In a period when recruitment and retention are crucial issues in health and social care the focus of this paper is:

? Who are the workforce of health and social care?

? What are the needs of that workforce?

? How safe is it for the much smaller partner, social care, to work together with the much larger health care?

The latter point heads us back to the sub‐title of the paper: can a duck sleep with a hippopotamus?

This question comes from an advert used in the UK for a bed manufacturer, where our British sensitivities and fear of sex prevents us from showing a man and a woman in a double bed, what the Spanish charmingly call a ‘cama de matrimonio’, a marriage bed, and instead we show a hippopotamus and a duck sleeping, safely, in the same bed.

To follow this analogy, we have to show:

? that health and social care are in the same bed;

? that one is as large as a hippopotamus, and the other as small as a duck;

? what the dangers are of this;

and ask the question:

? What is there in the place of ‘spring technology’ which would permit both to sleep together, and for the duck not to end up flat?

In doing so, I hope to answer the first three questions I posed.     

Mexican immigration and health care: a political economy perspective.

This paper examines the case of Mexican immigrants in the United States and their access to medical services within a political economy of health framework. Such an approach stresses that the provision of health care is independent of health factors per se and that access to health care is not equally distributed throughout a population. The first section reviews the three major concepts influencing medical anthropologists working within a political economy framework: the social origins of illness; the allocation of health resources; and fieldwork in Third World countries. The analysis then focuses upon the reasons for limiting immigrants' access to health care, followed by an examination of the socioeconomic characteristics of Mexican immigrants, including an undocumented immigration status, which limit their access to health care. Finally, the consequences of limited access to health services are suggested, including a low utilization of preventive health services resulting from the high cost of care combined with the immigrants' generally low income, lack of medical insurance and fear of using U.S. health services.     

Health technology assessment between our health care system and our health

In this contribution, I wish to explore the potential of health technology assessment and ethics for increasing our capacity to pre-empt the shortcomings and undesired consequences of modern health care while maintaining its benefits. Central is the presumption that in case of some health problems this cannot be done unless we explicitly reconsider some features of the modern health care system, especially those related to its strong reliance on scientific rationality and the strong role played by medical professionals. So as to both maintain the benefits of advanced health care and ensure that it produces less reason for concern, we need to reconsider our approach to rationality—and maybe even the way in which we build our health care system around that rationality. That is, we need to introduce an element of reflexivity. Two types of circumstances are being explored in which such reflexivity may prove worthwhile: controversies on side effects, and persistent problems encountered in optimising health care. Drawing on brief discussions of typical cases, we explore the potential of reflexive HTA and its methodical prerequisites. We conclude that ethicists may contribute to reflexive HTA, if they combine a hermeneutic—and often also participative—methodology with a solid understanding of the relation between the health problem under scrutiny and more general critique of the health care system. Insights from the areas of science and technology studies, as well as from social philosophy may be critical items in their tool kit.     

The role of families in the population crisis

The population crisis in European countries can be synthesized into two phenomena: the loss of vitality and the aging society. What are the main consequences of this crisis? Can the family play a determining role in helping to face and overcoming these consequences? In this paper we suggest promoting the family as a possible means to help sustain or bring about a recovery in the demographic health of society. The first section is devoted to an analysis of the demographic decline across European countries by examining converging patterns in culturally, politically, and historically different contexts. The second section explores more deeply the interrelations between the determinants of the population crisis and living arrangements. A picture of the new shape of families across Europe precedes an analysis of the changing patterns in living arrangements and their link to reproductive functions. A final section studies the extent to which the family influences the role of women in the labor market.     

Long-term care policy for the elderly in the Zaporozhye region of Ukraine: a case study of social development following the collapse of Communism

In this paper, we review the status of social policy for the elderly in Ukraine since the fall of Communism and the breakup of the Soviet Union. We specifically address the problem of "rebuilding" an income and services policy for the at-risk elderly after the unraveling of the system that existed prior to the fall of Communism. Also, we address some existing problems faced by the elderly in the health care system. Within this context, we present a case study of the current status of long-term care policy for the elderly in one province of Ukraine, the eastern province of Zaporozhye, encompassing the industrial city of Zaporozhye on the Dnieper River. This case study particularly pays attention to current attempts to promote a social development process of long-term care services for the elderly. It examines recent developments with respect to public sector organizations and voluntary sector organizations that are trying to provide necessary services to the needy elderly. With respect to the voluntary sector, the paper pays particular attention to the American Jewish Joint Distribution Committee (JDC) model of a largely externally funded NGO that provides comprehensive and integrated social supports, while emphasizing local empowerment and the use of volunteers, for the needy Jewish population in the province of Zaporozhye. Based on our findings, we make some proposals regarding the improvement of income and services policy with respect to the elderly in Zaporozhye and Ukraine.     

More responsibility, less control: psychiatric survivors and Welfare State restructuring

This paper is concerned with the implications of recent Welfare State restructuring for psychiatric survivors' citizenship status. Using the Province of Ontario as a case study, the paper examines the extent to which recent change in mental health care and social assistance programs has worked to facilitate or constrain survivors' ability to exercise control over their lives. Despite recognition of the importance of survivors' participation in the mental health care system in the late 1980s, recent years have seen a return to a more traditional treatment paradigm characterized by professional control. Concurrently, restructuring of social assistance programs has led to a decline in the real value of income supports and growing pressure on informal support networks. As a result, psychiatric survivors are increasingly held responsible for their own material well-being and public conduct, but are less able to exercise control within everyday life.     

A Review of the Current State of Negotiated Order Theory: an Appreciation and a Critique*

It is argued that the theory of negotiated order, which has remained largely submerged within a series of fairly specific “grounded” case studies of occupations, professions, and complex organizations in the health field, has a number of attractive qualities to it. As such, it represents one of the more exciting recent developments in the study of organizations The present paper examines the more recent historical origins of the theory, summarizes its major points, and critically assesses its strengths and weaknesses. Since most of the substance of the theory is found in studies of health professionals working in hospital settings, the examples used here are also derived from this particular body of literature. Some future possible directions which we believe will improve the overall explanatory power of the perspective are presented in the concluding section.     

Das soziale Kapital von Arbeitsgruppen und die Nebenfolgen seiner Verwertung

Thousands of studies have been done in order to identify ?key success factors“ which enable the management of firms to exploit ?group effects“. I will discuss some of the effets which were traditionally in the focus of management desires and management science: commitment and social support. My intention is not to discuss these ?factors“ and their operationalization as constructs, but as examples for the prevailing logic and paradigm of group research. The first section offers an explanation for the phenomenon, why this kind of research suffers an almost complete lack of empirical evidence and theoretical advance. The next section presents an analytical approach that explains two other phenomena: first, the contradictory results of small group research; and second, the ambivalence of group work from the perspective of the working. The third section gives an example for the application of the ?potential-oriented perspective“ in an empirical case study of group-centered reorganisation.     

Health Maintenance Organizations

Health maintenance organizations and similar pre-paid health plans are an alternative form of health care available to Medicare beneficiaries in some areas of the country. While proponents of HMOs have argued that these plans may be better suited than fee-for-service medicine to provide care to an older population, HMOs have played a relatively small role in health care of the elderly. This paper traces federal health policy relating to HMOs and Medicare and describes obstacles to HMO Medicare programs stemming from those policies. It then examines the Massachusetts experience in HMO program development as a case study of how state policy can play a critical role in implementation of policy objectives at a local level. The paper demonstrates how an active state policy involving the executive and legislative branches, elder advocacy groups, and the private sector created a public-private partnership to develop HMO programs for the Medicare population. When this paper was completed, however, Medicare HMO development in Massachusetts was at a standstill, waiting for several critical problems of federal policy to be resolved.     

Social work students dealing with moral dilemmas in the care for children and young people: an evaluation of moral case deliberation as an educational tool

Social work professionals face moral dilemmas. Evidence-based guidelines only partly help them to deal with these dilemmas. Recently, moral case deliberation (MCD) as a bottom-up aid has been successfully introduced into Dutch health care to help strengthen professional moral competence. This research investigates whether MCD can help future professionals caring for children and young people to deal with their dilemmas. Research questions are: (1) How do students evaluate two series of four MCD sessions related to moral dilemmas in cases they experienced in practice? and (2) Does MCD contribute to students’ ability to justify their decisions? Applying a mixed-method evaluation study, we found that students consider MCD highly important. They feel supported in their ability to justify decisions ethically. Most students value the challenge of thinking critically in MCD. However, some do not appreciate the uncertainties which come with this. One-third of the students prove able to justify their decisions ethically after attending MCD sessions. Robust conclusions about MCD as the cause of these results cannot be drawn on the basis of the study design. Suggestions are made for future research regarding the contribution of MCD to the development of competence in dealing better with moral dilemmas.     

Disease Mongering in Direct‐to‐Consumer Advertising and the Expansion of the Antidepressant Market

The recent trend toward health care consumerism is largely the product of market practices, which have instilled the notion of health care as a product to be purchased by informed, empowered consumers, rather than a service bestowed upon a patient by a paternalistic provider. In recent years, health care consumerism has been facilitated by direct‐to‐consumer advertising (DTCA) of pharmaceutical products. In this paper, we use the case of DTCA for antidepressant medications to examine medicalization techniques used to promote consumerism and establish and expand the antidepressant market. We used content analysis of DTCA from the 1997–2006 issues of a broad sample of women's, men's, and common readership magazines to identify techniques of medicalization, and we analyzed in‐depth interviews with magazine readers and antidepressant users to examine how such messages are received. Findings are presented within a framework of economic sociology, which allowed us to unveil the links between emotions and social action that undergird responses to medicalization techniques and consumption of advertised products.     

Changing health culture in rural Appalachia: Implications for serving the elderly

This article explores the dual themes of place and time as influences on health care service delivery to the rural elderly, through a case study of rural Appalachia. Traditional patterns of indigenous health care practice and values are contrasted with more “professional” formal models of health care service delivery that have entered the region. The result has been a clash of health care cultures. The continuing validity of this perspective is appraised in relation to apparent generational differences between the old-old and the young-old in the degree to which contemporary health care practices and values are adopted. It is concluded that traditional and contemporary health care cultures can be reconciled through an expanded vision of health care service delivery premised on: understanding health care within a total community context; redefining the role of the health practitioner; improving education of both the rural elderly and service providers; and enhancing communication in the rural health care environment.     

Does the Person‐of‐the‐Therapist Training (POTT) Promote Self‐Care? Personal Gains of MFT Trainees Following POTT: A Retrospective Thematic Analysis

As we recognize how taxing our profession can be, therapist's self‐care has become a salient topic in mental health. However, we are still discerning how to promote self‐care in our practice and in training. In this paper, we present a study on the personal gains that MFT students experienced after participating in the Person‐of‐the‐Therapist Training (POTT). We propose that the reported changes (better understanding of self, change to self, relational changes, and change as a process) constitute improvements in the trainees’ well‐being, and can therefore be considered self‐caring behaviors and practices. We state that models like POTT, that focus on embracing our vulnerability, can help clinicians be more caring toward ourselves. We conclude this paper by presenting clinical and training recommendations.     

The price of a loaf of bread: some conceptions of family support*

This paper reports on a case study of one local authority, and illustrates the different definitions of the term ‘family support’ employed by the different agencies within the authority. It provides a framework to analyse the contribution of the agencies according to the assumptions they make about methods and efficacy of intervention and access to and termination of intervention. It contrasts the findings from this framework with a needs based model of ‘family support’. Social work and health services tend to operate within a narrow, historically determined range, focusing most heavily on emotional support and behavioural change; whereas users and some of the other agencies are more likely to raise matters such as income maintenance, child care, leisure and education. The findings of the case study are discussed in relation to resources for families, key issues for the implementation of family support identified during the introduction of the Children Act, 1989, and the relevance of Social Services Inspectorate inspections to these issues. Copyright © 2002 John Wiley & Sons, Ltd.     

Revitalizing sociology: urban life and mental illness between history and the present

This paper proposes a re‐thinking of the relationship between sociology and the biological sciences. Tracing lines of connection between the history of sociology and the contemporary landscape of biology, the paper argues for a reconfiguration of this relationship beyond popular rhetorics of ‘biologization' or ‘medicalization'. At the heart of the paper is a claim that, today, there are some potent new frames for re‐imagining the traffic between sociological and biological research – even for ‘revitalizing’ the sociological enterprise as such. The paper threads this argument through one empirical case: the relationship between urban life and mental illness. In its first section, it shows how this relationship enlivened both early psychiatric epidemiology, and some forms of the new discipline of sociology; it then traces the historical division of these sciences, as the sociological investment in psychiatric questions waned, and ‘the social' become marginalized within an increasingly ‘biological' psychiatry. In its third section, however, the paper shows how this relationship has lately been revivified, but now by a nuanced epigenetic and neurobiological attention to the links between mental health and urban life. What role can sociology play here? In its final section, the paper shows how this older sociology, with its lively interest in the psychiatric and neurobiological vicissitudes of urban social life, can be our guide in helping to identify intersections between sociological and biological attention. With a new century now underway, the paper concludes by suggesting that the relationship between urban life and mental illness may prove a core testing‐ground for a ‘revitalized' sociology.     

THE EFFECT OF INSURANCE COVERAGE ON PREVENTIVE CARE

Despite the growth in health insurance products that differentially cover preventive care and nonpreventive care, little is known about how preventive care utilization responds to targeted changes in coverage. Using administrative data from a large company, this paper examines the implementation of an insurance benefit design which differentially increased the price of nonpreventive care while decreasing the price of prevention. Leveraging a difference‐in‐differences research strategy, we find that preventive care utilization did not increase and even declined due to the differential price change. This evidence indicates a meaningful negative cross‐price effect, suggesting that nonpreventive care and preventive care are complements. (JEL I13, I11)     

Closing the Loophole: A Case Study of Organizing for More Equitable and Affordable Access to Health Care in San Francisco

This paper presents in-depth case study of a successful hybrid political and community organizing campaign to ensure equitable access to health care through the perspective of a grassroots San Francisco community-based organization, the Chinese Progressive Association (CPA), which has been organizing low-income Chinese immigrants for over four decades. First, it outlines the Health Care Security Ordinance (HCSO), which, since its passage in 2006, has established a near-universal health care access program, helping to make health care accessible and affordable to individuals living and working in San Francisco. Then it presents the campaign to save the HCSO, focusing on CPA’s participation in the HCSO coalition. Finally, it discusses health care as it relates to the San Francisco’s affordability crisis and the political economic context in which it is taking place. Despite the limitations inherent in small case studies like this one, it nevertheless provides a valuable opportunity to better understand how one politically progressive city attempted to address the problem of grossly inequitable health care access through the lens of community organizing, advocacy, and coalition building. San Francisco, like many major American cities today, is being confronted with rapid gentrification and growing economic inequality—the backdrop to the HCSO. Through innovative experiments in social responsibility like the HCSO, however, the city has made leaps in health care access. It concludes with lessons learned from local organizing and advocacy to save the HCSO as these may inform other local efforts to promote health care for all.     

The production of understanding

While there is little doubt that sociological theory and research has had an important impact on the way people think about health and health care, mental health and medical sociologists are often confronted with challenges concerning the utility of the work that they do. Among the doubters are deans, funding agencies and family members. We are challenged by the ascendency of biological interpretations of human behaviors, by the incompatibility between the contextual view we prefer and the very strong individualistic orientation of our culture, and by the fact that we do not have an applied arm that trains the professionals who treat health and mental-health conditions. How do we respond to this challenge? The title of this paper gives a short answer: "The Production of Understanding." I propose that a powerful but under-recognized value of our work is the generation of explanations about health and mental health matters that help people understand the other side of an "us"/"them" divide. We produce understanding in a context in which misunderstanding is regularly constructed by powerful people who offer victim-blaming explanations for the circumstances experienced by people with less power. The production of understanding serves as an important counterbalance to this tendency. Our work shapes the way people think about problems related to health and mental health, limits the power of inaccurate victim-blaming accounts and provides understanding about why health and mental health are mal-distributed among people from different social circumstances.     

Modern health services and health care behavior: a survey in Kathmandu, Nepal

The most important problem regarding health service utilization in Third World countries is that established indigenous forms of health care are readily available and compete with modern health care. Thus, in addition to understanding the components of the decision to seek medical help, we must understand the conditions that affect the choice of a specific health care system. This study examines the impact of medical pluralism on the use of modern forms of health care in Nepal. The findings show that the presence of medical pluralism is a significant factor which delays use of modern health services. Policy implications are discussed, and the need for more research in this area is stressed.