On the Need for an Ethical Understanding of Health-Care Accountability

Abstract

In Sweden, as in many other Western countries, public health care is challenged by increasing demands for care and continuing budget deficits. Person-centred care (PCC) has been introduced as a new strategy to ameliorate the perceived fragmentation in care and is expected to decrease treatment time, reduce the need for return visits, as well as increase patient satisfaction. However, the changing clinical practices necessary for the PCC approach are assumed to require new accountability practices. This article is primarily an attempt to provide a conceptual analysis of ethical accountability, i.e. a type of accountability that takes into account the human relational responsibility, partial incoherence, and power of reflection. On the grounds of this characterisation, the article aims to provide a basis, among other things, for a discussion of the possibilities of identifying and empirically studying the multimodal expressions in communication that are relevant for this type of accountability. After an initial discussion of the debate on the limits of viewing accountability as transparency, we then turn to our methodological approach and introduce a conceptual analysis of accountability. Next, we discuss some additional features of accountability. Finally, we discuss the possibilities of empirically studying the institutionalisation of ethically informed accountability within person-centred health care.     

Building on the original strengths of direct payments to create a better future for social care

Confidence in the prevailing In Control model of personal budgets in the United Kingdom is beginning to waver. This raises the question of ‘where to next?’ for social care. Will we be returning to the monolithic system that typified services at the turn of the millennium – a system that is deeply oppressive for the great majority who lack the support and confidence to escape it by accessing a direct payment to manage their own support system? The Care Act has made no change to the basic process whereby it is councils that will decide what a person’s needs are, which will be met and with what resource. However, we argue here that the situation is far from hopeless. In Control’s analysis, while attractive to a neo-liberal political ideology, was based on a serious failure to understand the reasons for the success of direct payments. Whilst policy-makers saw it as a triumph for consumerist notions of choice, it is better understood as a triumph for needs-based planning, but carried out in a person-centred way. Learning the right lessons offers a new way forward to deliver a respectful and flexible service within the context of the Care Act.     

Triangulating perspectives to inform the development of a smartphone application for foster,kinship, and adoptive parents

Abstract

This article describes the initial phase of a user-centered, inductive process for informing the development of a smartphone application (app) to complement an in-person trauma-focused knowledge and skills training class for child welfare resource parents (i.e. foster, kinship, and adoptive parents). Based on the participatory design approach for technology development, a qualitative study was designed to capture and triangulate relevant knowledge and opinions from resource parents, training instructors, and parenting education experts. The most prevalent themes emerging among these stakeholder groups included the need for a simple app interface and the potential for the app to (1) cultivate connection, affirmation, and combat resource parent feelings of isolation; (2) reinforce in-class knowledge and support skill practice at home; and (3) monitor resource parent, child, and family progress over time. Detailed findings are presented, including direct quotes from focus group and interview participants and elaboration on the prevalent themes, which may benefit others in the early stages of human services app design and contribute to the creation of guidelines for the development of technology-based human services interventions.     

Moving from sustainable management to sustainable governance of natural resources: The role of social learning processes in rural India,Bolivia and Mali

The present paper discusses a conceptual, methodological and practical framework within which the limitations of the conventional notion of natural resource management (NRM) can be overcome. NRM is understood as the application of scientific ecological knowledge to resource management. By including a consideration of the normative imperatives that arise from scientific ecological knowledge and submitting them to public scrutiny, ‘sustainable management of natural resources’ can be recontextualised as ‘sustainable governance of natural resources’. This in turn makes it possible to place the politically neutralising discourse of ‘management’ in a space for wider societal debate, in which the different actors involved can deliberate and negotiate the norms, rules and power relations related to natural resource use and sustainable development. The transformation of sustainable management into sustainable governance of natural resources can be conceptualised as a social learning process involving scientists, experts, politicians and local actors, and their corresponding scientific and non-scientific knowledges. The social learning process is the result of what Habermas has described as ‘communicative action’, in contrast to ‘strategic action’. Sustainable governance of natural resources thus requires a new space for communicative action aiming at shared, intersubjectively validated definitions of actual situations and the goals and means required for transforming current norms, rules and power relations in order to achieve sustainable development. Case studies from rural India, Bolivia and Mali explore the potentials and limitations for broadening communicative action through an intensification of social learning processes at the interface of local and external knowledge. Key factors that enable or hinder the transformation of sustainable management into sustainable governance of natural resources through social learning processes and communicative action are discussed.     

The role of child care social work in supporting families with children in need and providing protective services—past,present and future

This article examines the way in which child care social work with deprived families has changed and developed since the inception of Children's Departments in 1948. It is argued that between 1948 and 1970 child care social workers enjoyed a fair measure of social support. A variety of reasons are considered for explaining this—specialization, smallness of size, privacy and a consensus about the needs of children. From the early 1970s it is argued that broader societal changes, including a shift away from social solidarity towards individualism, organizational changes and the advent of child abuse as a public concern, resulted in con?icting demands on child care social workers and a subsequent loss of credibility and con?dence. The 1990s have seen a return to emphasis on family support policies which has been further accelerated in the new millennium by New Labour's stated commitment to eliminating child poverty and creating better life opportunities for all children. The implications of these new developments for child care social workers engaged in meeting the needs of children living in highly disadvantaged families are considered. Copyright © 2006 John Wiley & Sons, Ltd.     

The successes and challenges of implementing individualised funding and supports for disabled people: an Irish perspective

‘Individualised funding’, which is rooted in the Independent Living Movement, has formed part of a global paradigm shift in support services for disabled people. Against the backdrop of international experience, a political system aligned with the United Kingdom and emergent critics of individualised funding, this article presents findings from an evaluation of four pilot programmes in Ireland. Exemplified by independent-skills development and community integration, these initiatives have been welcomed as a progressive development beyond traditional service provision, with perceived improvements across a range of organisational, personal, health and social care domains. The article explores the importance of ‘natural supports’ and how overly protective behaviour may unintentionally act as a barrier to full implementation. The findings also indicate that unnecessarily complex systems can lead to individual burn-out. Furthermore, a national resource allocation system working in partnership with existing social care professionals and the wider community is recommended, as is learning from overly simplified, group-based ideologies.     

The need for policy direction in the provision of care to the mentally ill: an interdisciplinary view

This paper argues that mental health care is underprovided, and that the role of nonprofit providers should be expanded for three major reasons. First, a positive externality exists since society, as a whole, benefits when those in need of mental health care consume care. External benefits include lower crime rates, lower unemployment, and less homelessness. Second, consumers of mental health care are mentally ill and often do not believe that they need care, underestimate their need, or believe that care is not worth the time or expense. Third, common law, to a large extent, is based on individual liberty, largely ignoring the benefits individuals receive from treatment. It is argued that government policy is needed to increase the supply of mental health care, through nonprofit agencies.     

Examining the need for cultural adaptations to an evidence-based parent training program targeting the prevention of child maltreatment

Evidence-based behavioral parent training programs (BPTs) have been recommended as a primary prevention strategy for child maltreatment, and use of BPTs is increasing. As these programs are implemented in new contexts and among new populations, the cultural relevance of these programs and need for adaptations or modifications must be considered. The purpose of this study was to assess the types of cultural adaptations that are being made to a widely implemented BPT, SafeCare, by providers working with families involved in the child welfare system, and to explore the need for more systematic adaptations. Eleven SafeCare providers, from six states, participated in individual, semi-structured interviews. Overall, the providers did not recommend systematic adaptations of the model for specific ethnic groups. However, they provided general and specific information regarding SafeCare components that require adaptation on a case-by-case basis, which is likely to be applicable to many BPTs. More research is needed to develop clear guidance about when and how to assess the need for cultural adaptations and how to institute adaptations that improve rather than weaken evidence-based programs. By sharing data and experiences, purveyors can contribute to the body of knowledge about adaptation.     

The market for foster care: an empirical study of the impact of foster care subsidies

When parents are suspected of child abuse or neglect, their children may be placed with foster families. We estimate the relationship between the monthly subsidies paid to foster families and the quantity of foster care services provided. The empirical model uses variation in subsidies and foster care populations within 37 states and the years 1987–1995. One innovation in our approach is that we exploit the idea that states do not appear to set market clearing rates, as evidenced by a foster home shortage during this time period. In this case of excess demand, variation in the monthly subsidy traces out the supply curve. Our results show that states with high demand may be able to use economic incentives to recruit foster families.

A call for greater attention to the role of employers in developing,transforming, and implementing family policies

The authors contend that employer-initiated workplace policies should be considered as part of the patchwork that constitutes U.S. family policy. To provide a background, historical evidence of employer-initiated policies intentionally used as family policies is summarized. The view is then explicated that failure to take economic conditions and workplace policies into account may lead to faulty conclusions about the reasons for major changes in family life. The current status of selected employer-initiated workplace policies and recent trends is summarized. Next, some of the dilemmas inherent in considering connections between government- and employer-initiated policies are identified. Finally, suggestions for future directions are offered. The article should be considered with the following caveat in mind: the focus is exclusively on the influence of policies on families, but families are not merely reactive. She received her Ph.D. and M.B.A. from The Pennsylvania State University. Her research interests center on relationships between jobs and family life, with emphasis on work-family relationships in small businesses, and on adult workers as developing individuals. Her research interests focus on the intersection of social problems and family problems, including families and work, coping with unemployment, and adult children as caregivers of dependent parents. She received her Ph.D. from Purdue University.     

‘If you want to have a future and a life,do an apprenticeship’: the expectations and realities of tradesmen’s transition to adulthood

ABSTRACT

Apprenticeship programs are promoted to facilitate youth’s transition from school-to-work, especially for those who might not otherwise attend postsecondary education. These programs may help youth achieve other markers of adulthood earlier. In this paper, we draw on qualitative interviews with Canadian young men in the skilled trades to explore whether they believe their educational choices have given them an advantage in their transition to adulthood. We also draw from the 2011 GSS, a nationally representative survey, and Cox modeling to examine three early adult transitions – home-leaving, first union, and first marriage – to determine if apprenticeship programs facilitate earlier transitions compared to other educational streams. Our respondents expressed that they transitioned to adulthood more quickly than their peers, due to early employment and avoiding student debt, however, many also had trouble finding stable employment and often took on debt related to their training. Using nationally representative data, we find tradesmen tend to leave home earlier than their peers, they form first unions at younger ages but marry slightly later than their more highly educated counterparts. Our results contribute to our understanding of how apprenticeship programs in Canada facilitate transitions to adulthood among a recent cohort of young men.     

Usability testing,initial implementation,and formative evaluation of an evidence-based intervention: Lessons from a demonstration project to reduce long-term foster care

The field of child welfare faces an undersupply of evidence-based interventions to address long-term foster care. The Permanency Innovations Initiative is a five-year federal demonstration project intended to generate evidence to reduce long stays in foster care for those youth who encounter the most substantial barriers to permanency. This article describes a systematic and staged approach to implementation and evaluation of a PII project that included usability testing as one of its key activities. Usability testing is an industry-derived practice which analyzes early implementation processes and evaluation procedures before they are finalized. This article describes the iterative selection, testing, and analysis of nine usability metrics that were designed to assess three important constructs of the project's initial implementation and evaluation: intervening early, obtaining consent, and engaging parents. Results showed that seven of nine metrics met a predetermined target. This study demonstrates how findings from usability testing influenced the initial implementation and formative evaluation of an evidence-supported intervention. Implications are discussed for usability testing as a quality improvement cycle that may contribute to better operationalized interventions and more reliable, valid, and replicable evidence.     

The experience of Jordanian care leavers making the transition from residential care to adulthood: The influence of a patriarchal and collectivist culture

The problems faced by young people leaving care to join the adult world are well-known. The present study adds to the current body of research on the subject by exploring the post-care experiences of young Jordanian care leavers. Forty two care leavers were interviewed, thirteen of whom also took part in a focus group. The interview data were analysed qualitatively. Jordanian care leavers described many experiences similar to those reported by young people leaving care in other countries including struggles to continue education, find accommodation, secure employment, and cope financially. Of particular interest was the more specific finding that the cultural values of patriarchy, family life, and collectivism characteristic of all Arab countries had a deeply pervasive impact on many of the care leavers' post-care experiences. The reasons that brought the young people into care, and the lack of family that most experienced upon leaving care, increased the risk of them being stigmatised. For many, managing their post-care identity in a patriarchal, family-based culture proved difficult and stressful. Although some care-leavers did receive exceptional, albeit informal support from friends and employers, the challenges faced by the care leavers were often exacerbated by the cultural values explicit in a society that is patriarchal, family-based and honour-bound. The policy and practise implications of these findings are briefly acknowledged.     

Exploring the unmet needs for creating an enabling environment for nurturing care to promote migrant child health in Bishkek,Kyrgyzstan: A theory-guided community-based participatory action research

Empirical evidence on community-driven child health promotion programs in disadvantaged migrant populations is limited despite various promotional strategies. Therefore, we implemented a developmental process to shape child health interventions using theory-guided community-based participatory action research (CBPAR) in a migrant community in Bishkek, Kyrgyzstan between 2015 and 2019.The collaborative and iterative CBPAR process was conducted through participatory workshops and focus group discussions with support from trusting and collegial partnerships between community members and the research team. The goal and scope of the intervention was guided by enabling environments for nurturing care, including the four domains of caregivers’ capabilities, empowered communities, supportive services, and enabling policies. Diverse interests and needs identified by community members were aggregated in the theoretical model and reflected in the intervention.Community-driven intervention is perceived as a culturally acceptable, sustainable, sensitive and relevant approach to solve problems. There are several challenges in conducting the CBPAR, such as the effort and time spent on building partnerships, co-learning and mutual understanding, and the power equilibrium involved. Despite this, the success of the CBPAR process provided opportunities for community mobilization, empowerment and sustainability of the intervention. Evaluation of the process and outcomes of the intervention provided community health researchers and practitioners with evidence of the theory-guided community participatory approach.     

The emergence of a voluntary sector and philanthropy in Vietnam: Functions, legal regulation and prospects for the future

A significant number and wide range of Vietnamese non-profit and voluntary organisations have developed since Vietnam embarked on a programme of economic reform in late 1986. Philanthropy has begun to grow as well, albeit more slowly. The non-profit and voluntary sector and the state, each face important challenges as development of the sector accelerates. The state has sought both to encourage growth of non-profit, voluntary and philanthropic institutions, but also to control the pace and directions of that growth. Those dual aims are reflected in the state's regulation of the sector since the mid-1980s. This article provides detailed information on the development of the non-profit sector in Vietnam. It examines some common problems many of the new non-profits and voluntary organisations face and discusses the rapidly changing environment for philanthropy in Vietnam. The article also reviews the developing legal environment for non-profits and philanthropy, compares the situation in Vietnam to other countries in transition, and situates the functions of the non-profit sector in Vietnam in the context of the emerging scholarly literature on functions and models of the non-profit sector and government/non-profit relations. formerly Program Officer for Vietnam, The Ford Foundation (1992–1995) The author is grateful to John Ambler, Nguyen Thi Van Anh, Mayusaki Ayuzame, Mary Jane Ballou, Barnett Baron, Christopher Bruton, Emmett Carson, Kathy Charlton, Le Trong Cuc, Ray Eaton, Mary Etherton, Virginia Foote, Peter Geithner, Neil Jamieson, Lisa Jones, Tim Kerr, Minh Kauffman, Viet Huong Kurtz, Borje Ljunggren, Toichi Makita, David Marr, John McAuliff, Noriko Ogawa, James Rockwell, John Rogers, Vo Quy, Tony Salzman, Yasuhiro Tanaka, Nguyen Van Thanh, Ngo Ba Thanh, David Thomas, Phan Toan, Mike Yeldham and Mary Zurbuchen, and representatives of the many Vietnamese groups interviewed for this article. This article represents the author's views and not those of the Ford Foundation nor any other organisation or individual. All translations from the Vietnamese, except as indicated, are by the author.     

Consultancy to a Care Home: The Influences of Family and Gender Roles,and of Race and Colonialism

This paper is an account and critical analysis of the psychodynamic and systemic consultancy that the author provided to a care home (and the voluntary organisation running it) over a period of about 16 months. In addition two emergent, linked themes are identified and discussed: family and gender roles in care homes, and racism and colonialism. Care homes are of course part of the society in which they exist and of which they are a product. This means that all the overt and covert psychological and social pressures, defences and trends that occur in the wider society, for individuals, families, groups and communities are also to be found in care homes and in the organisations that run them. They are not isolated from these forces, indeed, it is argued in this paper, the forces are intensified in the ‘hot house’ environment of a care home and, if ignored, avoided and denied, result in the exploitation, abuse and neglect of both staff and residents.     

The impact of mental health issues, substance use, and exposure to victimization on pregnancy rates among a sample of youth with past-year foster care placement

The purpose of this study is to (1) compare youth entering substance abuse treatment with and without a history of foster care placement to determine any differences in mental health, substance use, and exposure to victimization, and (2) determine if mental health, substance use, and/or exposure to victimization predict past pregnancy among the sample with a history of foster care placement. The pooled dataset consisted of 17,124 adolescents (12-17 years of age) who completed the Global Appraisal of Individual Needs at intake for substance abuse treatment in 2009. Of these, 366 (2.1%) reported having been in foster care in the past year. When compared with a non-foster care sample, the foster care sample reported significantly higher internal mental distress scores, behavior complexity scores, and general victimization scores, after controlling for race, gender, and level of care. Problems associated with substance use did not differ between groups, though regular tobacco use was present at a higher rate in the foster care sample. Multivariate logistic regression results revealed that, within the foster care sample, internal mental distress and gender predicted past pregnancy. There may be room for intervention within substance abuse treatment centers for youth with a history of foster care, who may be at risk for pregnancy if their levels of internal mental distress are high.     

Economics and public relations in a time of downturn: Dismal science,unseen history,and the need for dialogue

The major originating event of this special section was the ongoing crisis that continues to cast a shadow of financial depression across the globe and has led to calls for a radical rethink of economics. In this introduction we attempt to contextualize the special section's theme and articles with a view to sparking a deeper and longer dialogue – one that emphasizes the potential for positive disciplinary exchanges – between economics and public relations. As fields, they have been respectively characterized as the dismal science and the unseen history. In order to avoid such offspring as a dismal history of economics and an unseen science of public relations, we argue that the two need both to learn from, and to appreciate, each other. In the meantime, there is another crisis stalking public relations, and it is the possibility that the recent poor history of economics might be the imminent future of public relations.