Publication
International year of the family report (phase 1): an overview of academic attempts to define the family
7. Recommendations for stage two of HEBS International Year of the Family Project
Within the original brief for this report recommendations were requested regarding the second phase of HEBS IYF project. More specifically, I was asked to provide some suggestions concerning which policy makers and practitioners it would be most appropriate to include in the empirically based second stage of the project.
First, it necessary to think carefully about the ways that the terms policy makers and practitioners are being used. This is more than just a semantic point. When undertaking any piece of evaluative research it should always be recognised that the evaluation is taking place from a specific perspective (most commonly that of the organisation’s management). However, it is naive to assume that all members of the organisation share common goals and perspectives and are always pulling in the same direction. As Barrett and Fudge (1981), Lipsky (1980) and Sabatier (1986) have all shown, an adequate evaluation requires gaining an understanding of the ways in which ground level workers interpret and operationalise the mandates and directives received from above. Lipsky has gone so far as to argue that ‘street level bureaucrats’ actually make policy in many governmental organisations through the exercise of discretion in their dealings with the general public.
Sabatier (1986) has called for evaluative research to take account of both ‘top-down’ and ‘bottom-up’ approaches when attempting to understand policy making, policy implementation and policy outcome. Like Lipsky, he argues that an adequate analysis requires an understanding of front-line workers’ actions and the meanings that they attach to them. However, he also argues that it is necessary to locate the actions of front-line professionals within their broader organisational context. He makes the point that the directives and available resources from the bureaucratically higher parts of the organisation place important limits upon what front-line workers can and can not do.
In many ways the most obvious group of professionals to include in the second stage of this project would appear to be health visitors, due to their daily contact with families. As DeAth (1982) writes:
The health visitor appears to have a pivotal role in the life of the community and of her clients which has been well recognised by the caring professions as well as numerous select committees. She stands at the interface between ‘institutional’ knowledge (with her understanding of hospitals and medical providers, health and hygiene, drugs and technology gained during SRN training) and ‘community’ child-rearing patterns and expectations, life-styles and ‘life-chances’, local folklore and the range or lack of neighbourhood services ( DeAth p 283: quoted in Abbott & Sapsford 1990 p 127)
The importance of the work of Sabatier, Lipsky, Barrett and Fudge and others, lies in the way that they draw attention to the fact that front-line workers (in this case health visitors) in many ways actively create policy, but importantly, within the constraints of particular contexts. As noted in a preceding section, Abbott and Sapsford (1990) suggest that the fact that many health visitors work within or from a General Practice affects the opportunities available to them. Some support for this assertion is also found in the literature relating to the activities of practice based nurses. Thus Bradford and Winn (1993), in a recent study of General Practice based nurses, found that whilst many respondents agreed with the basic ideas of more radical health promotion, the medical-models they employed in their daily work were invariably conservative.
The implication of this may be that while many practice nurses recognise that health promotion has socio-political implications, the concept appears to be far removed from their working practice. ... although 22 per cent ranked the social change model highest, only two per cent said that it was the model they used in practice. Thus it seems that there is some agreement in principle with more radical approaches to health promotion, but their application in practice nursing is at present limited (Bradford & Winn 1993 p 95).
Interestingly, though, the review of work being undertaken in Glasgow for the Healthy Cities Project suggests that, in that Region at least, some health visitors are attempting to engage in health promotion as well as health education. The Community Development Strategy, therefore, includes a statement from a health visitor engaged in community development in Drumchapel. As she writes:
The health issues in an area like Drumchapel are many and complex, and there can be no one way to address the health needs. In working with the Project I have had the opportunity to use my health visiting training to the full- in the process of identification of health needs; increasing community participation in health activities and in decision-making forums; breaking down barriers between the agencies with input to community health work; and empowering local people to have more control of personal and local issues (Craige P in ‘Community Development Strategy: community support unit Glasgow health city project’-Draft July 1993).
As noted, there is limited recent academic work looking specifically at health visitors’ views of family life. Given the multiplicity of family types in Scotland, information would be useful on the ways in which health visitors view and interact with various forms of family and their views of correct and/or inappropriate gender roles. It would also be very interesting to know how the organisational context within which heath visitors work affects their views of their roles, in terms of health education and health promotion or some combination of the two. These are all areas worthy of empirical investigation and would make a valuable contribution to the International Year of the Family.
In order to gain an understanding of the contexts in which health visitors work it would appear necessary to ask them directly how they perceive the contextual pressures upon them. If resources allow it would also seem advisable to interview their daily line managers. This will provide data on the role that front-line team leaders expect health visitors to fulfil (this may involve interviewing General Practitioners but the situation appears to vary between areas and regions).
Equally, an adequate understanding of the role of health visitors engaged in health promotion and health education work with families requires speaking to their clients. It is only through meeting and talking with families that the implications of the worker’s advice and/or actions can be understood and located the within the context of the family’s daily life.
In addition to gathering these front-line views, following Sabatier, I would also advise that data be collected from health visitors’ senior managers (senior members of Health Promotion Departments might also be appropriate here). In this way it will be possible to gain an understanding of the role that these policy makers play in shaping the context within which health visitors work.
Within the preceding review of current (and recent) policies, programmes and initiatives aimed at the promotion of family health, it was noted that there are significant variations in the approaches taken by different Health Boards. For example, in the previous section it was suggested that the approach of Glasgow (particularly in the context of the Healthy Cities initiative) is significantly different to that of Argyll and Clyde. Within the empirical part of this project the taking of two contrasting regions or areas would appear sensible, as it would allow for comparative analysis and ultimately more understanding of the ways in which different policy contexts affect the work of front-line workers (in this case health visitors).
Clearly, whether the line of enquiry suggested is feasible will depend, in large part, on the available resources and the time schedule for the completion of the project. If it is not possible to take account of all of the suggestions made here, it is hoped that the issues raised will at least be of use when considering the direction of the second stage the project.