Power and change: primary health care at the crossroads in Sweden.

This paper is based on in-depth interviews with members of Sweden's medical interest groups involved in a national effort to control health care costs. Sweden is faced with escalating costs due primarily to a growing high technology hospital sector. Simultaneously, consumer demand for primary care services and for gerontological care is rising rapidly. The Swedish way of changing the health care system is described and an analysis of the power struggle between physicians, health care bureaucrats and politicians is presented.     

Driving to Work: The Front Seat Work of Paramedics to and from the Scene

The work paramedics do in the front of the ambulance on their way to and from the scene is central to the safety and well‐being of both paramedics and patients. However, most research on paramedics and emergency medical services assumes rather than empirically explores the actual happenings of what paramedics do in the front of their ambulance. In this article, I move beyond this taken‐for‐granted understanding of front‐seat work by taking readers in the front of the ambulance and exploring the hidden work paramedics do on their way to and from the scene. I draw on data from an institutional ethnography into the socially organized work and work settings of paramedics, which included over 200 hours of observations and over 100 interviews with paramedics. This article adds to research on the sociology of work and health and illness by focusing explicitly on how paramedics give meaning to their work setting, the social conditions and relations central to their work practices, and how their work knowledge is actually put into practice. In doing so, I shed light on an ever‐important occupational group in health care that has garnered little sociological attention to date.     

A model-guided process evaluation: Office-based prescribing and pharmacy dispensing of methadone

This article presents an exemplar of a model-guided process evaluation that specifies the treatment model, assesses its implementation, monitors the fidelity of the model throughout the project, assesses model exposure and absorption, and helps understand the program's intermediate effects (proximal outcomes) as well as final effects (distal outcomes). The New Mexico study on office-based prescribing and community pharmacy dispensing of methadone is a research demonstration project that phases a small group of female methadone maintenance patients out of methadone clinics and into a program where they will obtain their scheduled doses of methadone at pharmacies that work in collaboration with physicians and a social worker.The patient's methadone treatment will in this way become part of their overall health care. Early detection of problems of implementation (e.g., the omission of program content or the delivery of inaccurate information) enables the researcher to make adjustments before the problems become unmanageable and the integrity of the original research design is compromised. A model-guided process evaluation can critically inform health services research demonstrations designed for enabling continuous, ongoing feedback and improvement of client-related services.     

Complaints,Sensitivities and Responsibility: An Ethnographic Investigation into the Debates Concerning the Care of Bangladeshi Mothers in the East End

The subject of this paper is a maternity services awareness day organised by a community centre in the East End of London. In what I interpret as the fractured political landscape of Tower Hamlets (in East London), this event formed a rare focus for the diverse groups of people I worked with in my fieldwork and provides a focal point through which to reflect upon issues of diaspora, culture and health care. This paper attempts to analyse the public voices of a diasporic community which were challenging mainstream health provision. In this paper, I suggest that the voicing of complaint both reified and contested the needs of Bangladeshi mothers specifically, yet did not alter the services provided. The ways in which “culture” is used or discarded as a critical platform on which to base claims about health care are discussed.     

SHOPFLOOR CULTURES: The Idioculture of Production in Operational Meteorology

Each workplace operates within a cultural context in which local features of interaction influence how employees conceptualize their workplace self. Building on small-group research, I argue that understanding these idiocultures as action arenas helps to specify how group knowledge, practices, and beliefs are expressed and affect occupational identity. To demonstrate the power of microcultures, I analyzed local offices of the National Weather Service (NWS) through ethnographic methods. I focused on the Chicago office, demonstrating how its culture, which emphasizes autonomy and resistance to authority, shapes the staff's images of scientific practice and the contours of being a scientist. The culture is revealed in their joking relations as well as in other office traditions. I then compared this culture with that of Flowerland, a spin-up office established in the 1990s. These two offices use their cultures to differentiate themselves, creating distinct work practices. As all work groups have local cultures, giving greater attention to small-group dynamics helps us understand how workers define themselves, how cultures differ, and how the effects of these differences shape the experience of work.     

Intersex or Diverse Sex Development: Critical Review of Psychosocial Health Care Research and Indications for Practice

Intersex or diverse sex development (dsd) can be conceptualized as an aspect of bodily diversity that has particular psychosocial implications. This is a review of psychosocial health care literature, published from 2007 to 2017, focusing on the well-being of people with a diagnosis relating to sex development. The analysis I offer here takes a critical psychological approach, questioning norms and taken-for-granted assumptions. This approach works from the understanding that how we know and how we talk about a phenomenon affects people in material and life-changing ways. This article offers recommendations concerning health care communication, the importance of taking time for emotion, and the process of building supportive relationships. The research reviewed provides clear evidence of psychosocial harm that is done through genital intervention and evidence that parents do not routinely give fully informed consent before their children undergo treatment. Finally, I highlight key points and recommendations for health professionals, indicating how psychosocial professionals can contribute to health care and well-being in the context of dsd when appropriately resourced and trained.     

Rise of the social?: Socialization of care and gendered social economy in South Korea

This paper sheds light on the recent increase in social enterprises and cooperatives in the care services sector, in particular, in the context of socializing care from the family in South Korea. This paper pays attention to the dynamics between marketization and social protection and the emancipatory efforts to build rich market relationship. In this paper, first I explore the changes in the care regime and the development of the care labor market with a focus on Long Term Care Insurance for the elderly in South Korea. Then I review the care provision through Social and Solidarity Economy and various attempts to build rich market relations. Finally, I evaluate the range of efforts for socialization of care with gender perspective by using the framework which is derived from Fraser's (2013) scenario for emancipation.     

Measuring the quality of health care

This Issue Brief examines some of the issues involved in defining and measuring the quality of health care and in implementing quality measures. It discusses the importance of measures of health care quality in the evolving health care delivery system, examines some of the conceptual issues involved in defining quality of care, and discusses some of the measures of health care quality and how these measures have been implemented in the health care delivery system. The major impetus for quality assurance programs is cost management: it is an attempt to allocate scarce health care resources efficiently. This requires making choices among alternatives, which may mean that maximizing quality of care for whole populations may not maximize the quality of care for individuals. Quality, in terms of any single good or service, has a number of dimensions. Health care is a complex bundle of services, and each component service within an episode of care affects the other components and the patients differently. Moreover, patients differ in numerous ways, which means that similar symptoms may require different services if care is to be effective. Measuring quality of health care services requires accounting for all of these factors. In attempting to manage health care costs, employers and other private health plans have begun to employ process measures of quality, i.e., evaluating caregivers' activities, the decisions made at each step in an episode of illness, and the appropriateness of the care provided. Process is an important component of quality measures because it focuses directly on the uncertainty in the efficacy of treatment. Given this uncertainty, the logic of medical decision making is an important determinant of quality and cost effectiveness. Examining the process of care involves assembling a panel of physicians who review medical records to determine the appropriateness of the care received. Providers have increasingly found that their medical decision making and practice styles are being monitored by purchasers as new health care delivery systems are being formed. The American Medical Association found that 39 percent of surveyed physicians were subject to clinical profiling.     

Work roles and definitions of patient health

Taking its starting point from Berger and Luckmann's (1967) sociology of knowledge and Schutz's (1962) phenomenology, this research explored the social construction of definitions of patient health made by nurses, physicians and social workers in a large American geriatric care facility. The study focused on one patient unit and was based on a content analysis of the notes made in the medical records of 38 patients. In addition, focused interviewing and limited nonparticipant observation were used. The research suggests that staff relations with patients are in large part a product of work roles, a concept which can be divided into three aspects: medical role ideology, work load and work responsibility. Further, the work role structures definitions of patient health status. For this reason nurses, physicians and social workers had different definitions of the same patient at the same time. Differences were most marked in terms of definitions of stability and senility.I wish to thank Phil Brown, Martin Martel, and Al Wessen for helpful comments on earlier versions of this paper.     

The managed heart revisited: health and social control1

In this paper I investigate emotional labour in the field of nursing. I show how new ideologies of health promotion have become attached to the prior agenda and already-embedded relationships which structure health provision. Beginning with an outline of health promotion principles and policies the paper goes on to trace how the radical dimensions of health promotion philosophies are subverted in practice by discussing data from a research project into nursing roles in health promotion. I present the data to show how nursing's focus on relationships and relationship skills create divisions of knowledge and information between ‘expert’ discourses located in the institutions of health provision and the everyday agenda of the populations using their services. In the final section of the paper I argue that a focus on the deployment of emotion work in specific social and institutional contexts provides a perspective on emotions as resources that are consciously drawn upon by actors in order to achieve socio-cultural and wider political ends.     

Producing ‘internal suspect bodies’: divisive effects of UK counter‐terrorism measures on Muslim communities in Leeds and Bradford

Research on UK government counter‐terrorism measures has claimed that Muslims are treated as a ‘suspect community’. However, there is limited research exploring the divisive effects that membership of a ‘suspect community’ has on relations within Muslim communities. Drawing from interviews with British Muslims living in Leeds or Bradford, I address this gap by explicating how co‐option of Muslim community members to counter extremism fractures relations within Muslim communities. I reveal how community members internalize fears of state targeting which precipitates internal disciplinary measures. I contribute the category of ‘internal suspect body’ which is materialized through two intersecting conditions within preventative counter‐terrorism: the suspected extremist for Muslims to look out for and suspected informer who might report fellow Muslims. I argue that the suspect community operates through a network of relations by which terrors of counter‐terrorism are reproduced within Muslim communities with divisive effects.     

Epistemic authority and the gender lens

Researching ‘hidden’ forms of social inequality such as gender often poses particular challenges. Not least of these is how to uncover such dimensions of social life whilst preserving the perspectives of research participants, who may not consider such matters relevant to their lives, particularly if other forms of identity or oppression are more prominent for them. Here, I reflect on these issues in the context of researching user involvement in mental health services from a feminist perspective. I show how ‘uncovering’ gender and other forms of social inequality in the field was aided through adopting a wide analytical lens focusing on power, along with reflexivity and openness in discussing my own political analysis and commitments in relation to the study area with the researched. I also describe how I attempted to resolve the epistemological‐ethical issues involved through conceptualising these in terms of ‘situatedness’ and gender salience and adopting a feminist standpoint which emphasised what researchers can, and indeed should, bring to the research enterprise. Related issues of power and empowerment in the research process are discussed.     

Trust and Health Care

Trust is believed to be particularly salient to the provision of health care, and since the establishment of the National Health Service (NHS) in the UK, trust has played an important role in the relationships between its three key actors: the state, healthcare practitioners, and patients and the public. Service users trusted the judgement, knowledge and expertise of health professionals to provide a competent service that met their needs, and they trusted the state to ensure equity in the allocation of public goods and services. These implicit or taken-for-granted trust relationships have, it is claimed, been challenged as a result of the introduction of changes in the organisation and funding for the health service, in the regulation and performance assessment of health professionals, and in public attitudes to health care and scientific medicine. This paper considers the influences of social changes and recent policy and professional initiatives in health care on the structure of trust relations in health care in the UK. It presents a theoretical framework for examining trust relations using the NHS as a case study and concludes with an agenda for future research.     

Oral health in long-term care: The implications of organizational culture

When an investigation designed to compare extant models of delivering oral health and dental services to the institutionalized elderly revealed that structural variables explained very little of the difference between effective and ineffective programs, secondary analytic techniques were employed to consider alternative explanations. The original study was a program evaluation based on a comparative case study of 12 long-term care (LTC) facilities. Data for each case included interviews with administrators, care providers, family members, and residents, administrative documentation, and clinical measures of oral health from the residents. The secondary analysis revealed the mechanisms through which the organizational context of each facility influenced the effectiveness of the oral health services. In addition, it revealed how administrative and leadership issues influenced the quality of care.     

Free enterprise, professional ideology, and self-interest: an analysis of resistance by Canadian physicians to universal health insurance

Under Canada's universal health care system, physicians are remunerated through government-run health insurance plans; a private market for physicians' services is virtually nonexistent. A proposal to ban the practice of extra-billing, whereby some physicians billed patients for amounts over and above insured rates, met with physicians' opposition. The particular constellation of legislative, social, and political events that followed the proposed ban presented a unique opportunity to explore the nature of the medical profession's resistance to encroachment on professional autonomy. The results of this survey of physicians in four specialties (N = 313) in metropolitan Toronto suggest that resistance to universal health insurance is complex; it involves a prevailing social ideology among physicians, which happens to be antiwelfare and conservative generally, entangled with economic self-interest and a specific set of beliefs about medical practice and physicians' rights and privileges.     

Managing physical and mental health conditions: Consumer perspectives on integrated care

Despite the growing trend of integrating primary care and mental health services, little research has documented how consumers with severe mental illnesses (SMI) manage comorbid conditions or view integrated services. We sought to better understand how consumers perceive and manage both mental and physical health conditions and their views of integrated services. We conducted semi-structured interviews with consumers receiving primary care services integrated in a community mental health setting. Consumers described a range of strategies to deal with physical health conditions and generally viewed mental and physical health conditions as impacting one another. Consumers viewed integration of primary care and mental health services favorably, specifically its convenience, friendliness, and knowledge of providers, and collaboration between providers. Although integration was viewed positively, consumers with SMI may need a myriad of strategies and supports to both initiate and sustain lifestyle changes that address common physical health problems.     

Managed care and the rationalization of mental health services

Managed care represents a response to the wider institutional demand for technical rationality and efficiency, and it may be in conflict with professionally generated logics of mental health care which emphasize the delivery of quality care, as well as providing services to all who need care. The organizational and policy conundrum is to balance conflicting institutional demands for efficiency (cost savings) and effectiveness (access and quality). This paper examines managed care in one public sector mental health care system that has attempted to incorporate the principles of managed care into a community based system of care and to overcome the potential contradictions between demands for efficiency and professional logics of care. Both qualitative and quantitative data are used to examine changes in organizational structure and service offerings; providers' experience of managed care, and the effect of managed care on working conditions and work experiences, and changes in the goals of the organization as measured by the specification of client outcomes. I find that, while increased performance accountability and outcome assessment (in keeping with demands for efficiency) have the potential to improve mental health care services, in fact, providers report that the primary effect of managed care has been an emphasis on cost containment, and there has been a corresponding de-emphasis on the provision of community based services for clients with long term care needs. However, there is potential for professional logics to be maintained by larger institutional forces demanding quality care.     

Why self-care fails: Implementing policy at a low-income sickle cell clinic

This paper addresses health care service delivery—its practice and its meanings—to a low income African-American population. Drawing on fieldwork and interviews at a sickle cell clinic, I explain why assumptions in the literature on self-care do not apply to a population historically excluded from access to health services. Self-care, a practice in which the individual assumes primary responsibility for health care, is typically seen as empowering patients and reducing the use of professional health services. While these predictions may apply to white, middle-class populations, they were not borne out in the low-income African-American population I studied. Self-care did not increase client control, nor was it associated with sparing use of health services. In this paper I explain why this was the case. I argue that conditions of poverty and the meanings clients attach to self-care impinge upon the implementation of policy producing results directly contrary to those that are predicted.     

Towards a More Social Orientation in Gerontechnology: Case Study of the “Reminiscence Stick”

The purpose of this article is to investigate, through a case study, how social orientation can be realized in gerontechnology's objectives. The focus is on user-driven development process of an “mStick,” which is a tool for storing various biographical material: photographs, texts, audio and video clips, and using it in elderly care services. Qualitative data were collected in 11 pilot cases. The content analysis was used to investigate how the “Gerontechnology's Five Ways”: prevention, enhancement, compensation, care, and research, were applicable especially from the perspective of social implications. The mStick acts as a prevention by offering meaningful contents to life, as enhancement by offering a possibility to utilize elderly person's resources. It compensates weakening abilities by preventing the world from becoming narrower. In care, it helps to see patients as whole human beings with unique biography. In addition, mStick offers potential for, for example, applications in memory research. The implication of this study is to pay attention to gerontechnology's role in supporting the social nature of the human being. This may contribute to renewing caring culture towards a more social and biographical orientation. Limitations of this study include focusing on the early development and implementation process with no long-term use data.     

The effectiveness of health care cost management strategies: a review of the evidence

This Issue Brief discusses the evolution of the health care delivery and financing systems and its effects on health care cost management and describes the changes in the health care delivery system as they pertain to managed care. It presents empirical evidence on the effectiveness of managed care and concludes with an analysis of the potential of future health care reform to influence the evolution of the health care delivery system and affect health care costs. Between 1987 and 1993, total enrollment in health maintenance organizations (HMOs) increased from 28.6 million to 39.8 million, representing an additional 11.2 million individuals, or 4 percent of the U.S. population. At the same time, new forms of managed care organizations emerged. Enrollment in preferred provider organizations increased from 12.2 million individuals in 1987 to 58 million in 1992, and enrollment in point-of-service plans increased from virtually none in 1987 to 2.3 million individuals in 1992. In addition, the percentage of traditional fee-for-service plans with some form of utilization review increased to 95 percent in 1990 from 41 percent in 1987. Measuring the effects of the changing delivery system on the costs and quality of health care services has been a difficult task, resulting in considerable disagreement as to whether or not costs have been affected. In a recent report, the Congressional Budget Office recognizes two new major findings. First, managed care can provide cost-effective health care at a level of quality comparable with the care typically provided by a fee-for-service plan. Second, independent practice associations can be as effective as group- or staff-model HMOs under certain conditions. In the future, we are likely to see a continued movement of Americans into managed care arrangements, an increase in the number of physicians forming networks, a reduction in the number of insurers, an increase in the number of employers joining coalitions to purchase health care services for their employees, and a health care system that is generally more concentrated and vertically integrated.