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This paper reports a qualitative study on the contribution of a Program of Education through Work (PET) in Healthcare, based at a Brazilian State University, to interprofessional education. Data were collected from ten undergraduate students of Nursing, Medicine, and Phonoaudiology (speech therapy), who were part of PET at the University. Data were analyzed using the Discourse of the Collective Subject technique. Central ideas were gathered into three categories: (1) teamwork and interprofessionality; (2) PET influences on SUS (Brazilian Unified Health System); (3) teaching-service-community integration. The study found evidence that PET enabled the students with opportunities to be involved in an education that supported the SUS principles and guidelines and to engage with interprofessional learning where there were exchanges of different professional experiences. The PET also supported the development of critical thinking for professional performance, as well as an integrated teaching experience that could support community development. [ABSTRACT FROM AUTHOR]

Poor health and disease and the nature of interventions to ameliorate them typically generate opportunities and costs. What diseases are prevalent, which interventions are favoured and what factors fuel the nature of health interventions are recurrent concerns for political economists. This paper examines the prevailing viewpoints about what health policy works and what does not. Drawing on evidence from developing countries, it shows that there are many deficiencies in the prevailing orthodoxy which emphasises state, market, and civil society solutions. The paper suggests that health policy debate must be refrained around poverty and social inequality, constructs which are often subordinated to attaining grand ideological goals. [ABSTRACT FROM AUTHOR]

This concluding paper draws together the dominant themes across the papers published in this issue. The majority of the papers clearly point to disparities between the aims of policy-makers and mental health workers. Using a variety of perspectives and methods, the authors of these insightful papers argue that modernist, rational approaches to structuring and evaluating services are at odds with the professional needs of mental health workers. At one level this critique is self-evident given the messiness and uncertainties inherent in working with service users whose individual problems require flexible approaches tailored from a broad and evolving practice-base. For some authors, the focus is epistemological and methodological; they offer much needed examples of analysing policy construction, interpreting statistics and the concurrent application of the widely used concepts of medicalisation and structural inequality. Together, the papers indicate that the progress of mental health reform in many western countries remains inconsistent and, in some cases, obstructive to effective professional practice. [ABSTRACT FROM AUTHOR]

In Australia we have become preoccupied with the potential adverse impact of our ageing population on our health and social systems. The projected cost of having increasing proportions of our population in the over 70s, retired, chronically ill category of the demographic profile is emerging as a major challenge for governments and private insurers: so much so in fact that the government is now urging older people to stay at work longer. In America, new approaches to the management and self-management of chronic diseases have been invoked to encourage and support older people to improve their quality of life and reduce their recourse to and dependence upon health care technologies, clinical interventions and health care management systems. Unless this is achieved, it is argued, the cost of looking after this emerging ‘bubble’ of elderly people will become increasingly unsustainable as fewer and fewer (proportionately) younger people work to pay the taxes that support ageing, retired, sick and dependent populations. This paper argues that we are at real risk of having our economic wealth and productivity impeded and truncated by the financial burden of looking after high demand and high cost dependants at the aged end of the social demographic. This paper offers an alternative view of our ageing population, as well as highlighting some of the assets we have in our elderly populations, and providing suggestions as to an alternative view of the phenomenon of ageing that incorporates elements such as flexible working arrangements and the application of new, enabling technologies. This approach to our ageing population dilemma is predicated on a concept of lifelong learning and social participation along with better preventive and early intervention systems of health care. [ABSTRACT FROM AUTHOR]

This article deals with the social democratic aspiration of equitable access to health care in Bulgaria, a country in transition since 1989 from communism and a command economy to democracy and a free market. The focus is on access to health services and resources after the introduction of a universal health insurance system, with particular reference to formal and informal out-of-pocket payments for health care. The paper reports empirical results from a national household expenditure survey, supplemented with a semi-structured interview, conducted at the end of the survey period (April-May 2002). The results bring to light the groups in society who suffer most in this scenario: the poor, Roma, older persons and those living in towns and villages. The study reveals that the stated aim of the National Health Insurance Fund, to provide equitable access to health care, is a mirage rather than a reality, as the vast bulk of health care is self funded. This paper has particular significance for understanding the challenges faced by post-communist states in their attempts to achieve social democratic health care reforms. [ABSTRACT FROM AUTHOR]

Background: Consumers and consumerism in a healthcare context are often read as evidence of creeping privatization and marketization. This paper considers discourses of consumption, in a mental health context, from data collected in the Republic of Ireland. Drawing on typifications of western welfare regimes, it will consider processes of commodification and consumption. Aims: The purpose of this paper is to explore the political connotations of the consumer discourse and to focus attention on the implications of utilizing discourse(s) of consumption for service users. Method: Data were generated through interviews with ten mental health service users who were members of mental health social movement organizations. This was analysed using a discourse-analytic technique. The analysis considers consumer discourse(s) and delimits the utility of this way of talking about being a service user. Results: The impacts and inferences of using a consumer discourse are identified. Under some conditions it can be a positive event for the healthcare consumer, but the discourse tends to favour the healthcare professional and/or the state, in that it implicitly reasserts the primacy of the medical model. Conclusion: The consumer discourse is a complex construct that speaks to and for both the state and the service user. However, use of this discourse carries political and therapeutic connotations for the service user. The political connotations relate to the consumer discourse as a feature of a state sanctioned re-positioning of healthcare provision within a more explicitly market based context. The therapeutic connotations relate to a lack of genuine alternative explanatory systems to that of the medical model and an often implicit championing of medical discourses as evidenced in the consumer discourse. Declaration of interest: This research was in part funded by a scholarship from the Irish Research Council for Humanities and Social Sciences (IRCHSS). [ABSTRACT FROM AUTHOR]

This paper discusses the role of video-based research methods in social research. The paper situates these methods in the context of rising levels of visibility of professionals in government-funded organisations. The paper argues that while visual research may appear to play an ambiguous role in these organisations, it can also enable practitioners to confront the encroaching demands of post-bureaucratic work. To ground its argument, the paper presents an account of a video-ethnographic project currently underway in a local metropolitan hospital. This project focuses on negotiating understandings about existing care practices among a team of multi-disciplinary clinicians. Visual data gathered as part of that project are presented to specify issues which have thus far arisen during the project. Against this empirical background, the paper turns to considering the ambiguous potential of video-based research. The argument developed here is that, besides potentially exacerbating the pressure already imposed on clinicians - thanks to audit, surveillance and risk minimisation - video-based research may provide staff with new resources and opportunities for shaping their increasingly public and visible work practices. [ABSTRACT FROM AUTHOR]

Social scientific attention has recently focused upon the private regulation of Britain's burgeoning night-time economy by door supervisors or ‘bouncers’ as they are more commonly known. Contributing ethnography to this literature, this paper explores bodily risk among doorstaff in Southwest Britain. The commonly perceived association between doorwork and high levels of violence renders this a demonised occupation yet doorstaff may also be in physical danger when policing urban nightspots. Centrally, this participant observational study—grounded in the phenomenological ‘foreground’ or lived experience of risk — explores bodily danger within the door supervisors' routine night-time contexts. Interrelated social, cultural and economic factors associated with the attenuation, minimisation or avoidance of physical harm are also noted. Describing voluntary and other-imposed occupational health risks, including physical violence and illicit drug-taking, furthers an appreciative understanding of why doorstaff may simultaneously be in danger and dangerous. More formally, this paper, in underscoring the importance of the ‘lived body’, also supports recent theoretical calls for an embodied sociology. Sociological reflection on health, risk and society, it will be argued, must be grounded in the inescapable corporeality and emotional vicissitudes of actual flesh and blood bodies less it ride roughshod over complex social reality. [ABSTRACT FROM AUTHOR]

The production of sociological knowledge in Australian universities is explored through an empirical study of research papers published in a selection of academic outlets between 1960 and 2011. Drawing on theories concerning scholarly practices, institutional formation and the sociology of knowledge, questions are posed about the factors that shape and structure the production of sociological knowledge about health and medicine. The concept of intellectual schools is examined, with evidence sought for the presence of these 'knowledge networks' in the Australian context. The study suggests the formation and maintenance of schools are subject to structural factors within the university sector, specifically the relative wealth and prestige of the university and the dictates of the higher education market. [ABSTRACT FROM AUTHOR]

With the commodification of healthcare in general and of private health in particular, it is difficult not to acknowledge the growing influence of competition and 'the market' in shaping the way that nurses' work is managed by private hospitals and by nurses themselves. This paper explores the discourses shaping nurses' work in private healthcare, drawing upon data from an ethnographic study conducted in one Australian acute care private hospital. The framework for analysis relies on an exploration of the mentalities and governance of nurses' work in such a setting. The study shows how marketing and performance measures are believed to ensure the viability of the enterprise while simultaneously commodifying nurses' caring work. It is this work that remains invisible to the healthcare system and the hospitals where they work. [ABSTRACT FROM AUTHOR]

The 21st century will be characterised by aged and ageing nations, making eldercare a growing concern. Most eldercare in most nations will be provided informally, primarily by female family members. Helping these people understand the dimensions of eldercare is a key to effective and cost-effective caregiving. The Person-Environment Model (Lawton and Nahemow 1973) is proposed as a theoretical framework for understanding, assessing, and optimising family-based caregiving. This paper presents findings from a qualitative study of informal rehabilitation caregiving provided to elderly stroke survivors in Thailand. Four main rehabilitation dimensions (biological, psychological, social, spiritual) are identified, as are three main caregiver needs (information, assistance, and support). We suggest that while the Person-Environment Model is useful in developed nations, it is perhaps more valuable in societies where fewer options to family-based eldercare exist, and thus where effective informal eldercare is more critical. Implications for education and training of health care providers are also discussed. [ABSTRACT FROM AUTHOR]

This paper examines the extent to which US citizenship status affects the probability of a person's having a usual source of care and the predictors associated with access to health care among non-citizens. The research is founded on the analysis of data from the 2005 California Health Interview Survey (CHIS) (n = 33,187 adults, ages 18–64). Guided by a modified Andersen model of access to health care, the researchers conducted a series of logistic regression analyses using the survey data to compare native-born citizens with non-citizens who were 1.6 times less likely to access a usual source of care. Among non-citizens, insurance status, shorter duration of residence in the United States, and lower levels of English proficiency were related to a lower probability of having a usual source of care. Based on this research it is argued that affordable health care and health insurance options and access to culturally and linguistically sensitive services are needed to increase access to health care among these identified subgroups of non-citizens. [ABSTRACT FROM AUTHOR]

Health researchers in a number of settings are expressing concern about the 'gap' between what we 'know' about the social determinants of health and of health inequalities, and the lack of action based upon this 'knowledge'. Indeed, the 'know-do gap' has become almost a mantra echoed across international and some national institutional sites. This paper examines how the 'problem' of the 'gap' is understood and represented in dominant and sub-dominant conceptualisations. It highlights what is missing from these representations: adequate reflection on changing modes of governance of research management. Where once there was a degree of separation between research production and government policy, increasingly there is congruence between these governmental functions. This congruence means that the problem we face today is not a 'gap' but rather a 'fit' between what we 'know' and what we (don't) do regarding SDH. [ABSTRACT FROM AUTHOR]

The purpose of this paper is to explore the relationship between the concepts market orientation and organizational performance for nonprofit organizations. To understand the nature of this link in the nonprofit context, the authors will discuss and elaborate on the applicability of both concepts to nonprofits. They will develop multidimensional notions of "societal orientation" and "nonprofit organizational performance," which fit the specific operating environment of nonprofit organizations engaged in the provision of health and social services. The authors also propose a conceptual framework that relates both notions and present the main underlying propositions. They conclude by suggesting items to empirically measure both constructs and venues for future research. [ABSTRACT FROM AUTHOR]

This paper presents a complex, but realistic, picture of the lived experience in assisted living (AL), and provokes thoughtful reflection about the operational and ethical challenges faced in the delivery of care to an increasingly frail population in a typical AL facility. Developed from the findings of a two-year qualitative research project, the case represents a composite of selected data collected at five AL facilities that participated in the study. Students will participate in individual and small group exercises that challenge them to identify everyday ethical concerns in AL, and to suggest ways that management can address these issues. The case is suitable for cross-disciplinary use, and can be effectively applied in the fields of management, health care administration, sociology, gerontology, social work, and nursing, either on the graduate or undergraduate level. It is especially well suited to courses that incorporate the topics of long-term care, senior housing, or ethics. [ABSTRACT FROM AUTHOR]

The aim of this paper is to explore how the avoidance of death preoccupies the focus of most health professionals, including policy makers, in the western world, and the implications of this for the lives of people with chronic diseases. Avoiding death has become the ultimate challenge in the provision of contemporary healthcare. An implication of this way of thinking for people with chronic diseases is that their chronic disease is then positioned as something which will produce a death which could have been avoided. Such a death is then viewed as failure, not only biological, but also social. However, such failure is also position [ABSTRACT FROM AUTHOR]

This paper reports on a recent population-based study of the last months of life of 1071 people in Western Australia who died from a chronic condition. Data was collected from death certificates and telephone interviews of primary carers who acted as proxies providing second hand accounts of the severity of the deceased person's symptoms and sources of concerns, their awareness and acceptance of dying, and experiences of the health care system. We present descriptive statistics and quotes supporting our premise that dying in Australia is largely mismanaged. We base our assertions on three themes: dying with multiple conditions and symptoms; awareness and acceptance of dying; and support during the dying process. Each theme illustrates the difficulty of self-managing complex conditions, the failure of the health care system to acknowledge this complexity, and the need for a more radical and social approach to the management of dying. [ABSTRACT FROM AUTHOR]

The question we raise in this paper is whether the educational gradient in avoidable mortality differs from overall and non-avoidable mortality among men and women in Norway. By avoidable deaths we refer to deaths caused by diseases that are either treatable if given appropriate medical care, or preventable if available preventive measures were implemented. The data set is derived from official administrative registers and includes all Norwegian men (1 107 427) and women (1 087 842) aged 25-67 years with information about status alive/dead during the period 1994-1999. Adjusted for sociodemographic and socioeconomic factors, education forms a marked and independent gradient in overall and non-avoidable mortality and an even steeper gradient in avoidable mortality - in particular in ischemic heart disease and preventable deaths. The educational gradient is shallower for deaths considered treatable by health care, but is still present. These patterns apply to men and women alike. The findings of our study suggest that health care and health policies may play a role in reducing inequalities in deaths that are 'avoidable, unnecessary and unjust'. [ABSTRACT FROM AUTHOR]

This paper examines the governance of the medical profession in the UK. As in many other countries, external and internal pressures have brought a shift in relations between the state and medicine. From a relatively protected position within the British NHS, where clinical autonomy, social status and involvement in a corporatist politics, the context in which doctors practise has undergone radical change. In common with many countries, the UK has turned to competitive markets, and state-sponsored regulatory measures to boost performance. As a consequence, state domination of the health policy agenda has increased replacing a corporatist politics and doctors' individual clinical autonomy has been reduced. Moreover, the existing system of self-governance is in question. It is argued that, nevertheless, there is evidence of different forms of accommodation. The medical profession continues to control a valued knowledge base, retains its social standing and is able to reap economic rewards. A more plural form of medical leadership may emerge better suited to assuring quality in patient care. [ABSTRACT FROM AUTHOR]

More than 20 years have elapsed since the book that is the subject of this special edition was published. The aim in this scene-setting introductory paper is to undertake a stock-taking of status of doctors, doctoring and professionalism as we head into the 21st century. It considers the various challenges to medical dominance of health systems including neo-liberalism and economic rationalism, a growth in consumerism and associated litigiousness, the change from a cottage industry basis to mass markets as medicine has been industrialised, the rise of complementary and alternative medicine (CAM) and changing roles of other health care professionals. [ABSTRACT FROM AUTHOR]

This paper deals with the dynamics of medical dominance and patient choice, primarily within the Britain, with reference to a range of other European countries too (including Germany, France and Greece) for comparative purposes. It will draw upon two concepts in particular: 'responsibilisation' and 'proto-professionalism', the first undermining medical dominance the latter reinforcing it. The ongoing influence of a neo-liberal and managerialist agenda has eroded the certainties of the welfare state and the assumptions underpinning the dominant role of the medical profession, which has been subjected to increasing external state regulation and control (Dent 2003a). These reforms, which are associated with New Public Management, have been aimed at bringing the cost and quality of health care more effectively under the control of the state. This has involved redefining the compact or contract between the medical profession, public and the state. In this project greater emphasis is being formally given to the wishes of patients. Rather than the physician claiming to be the patient's voice it is now the state administration's assertion to have provided the patient with their own voice(s) - and choices. [ABSTRACT FROM AUTHOR]

There has been a renewed interest in collaborative models of health care delivered by 'interdisciplinary teams' of providers across several health care systems. This growing phenomenon raises a host of issues related to the management of professional boundaries and the contemporary state of medical dominance. In this paper, we undertake a critical analysis of the factors both promoting and impeding collaborative care models of primary and mental health care in Canada and the U.S. The data our arguments are based upon include a combination of documentary and interview data from key stakeholders influential in various collaborative care initiatives. Based on these data, we develop a conceptual model of the various levels of influence, focusing in particular on the macro (regulatory/funding) and meso (institutional) factors. Our comparative policy and institutional analysis reveals the similarities and differences in the influences of the broader contexts in Canada and the U.S., and by extension the different ways that the structural embeddedness of medical dominance impinges upon and reacts to recent policy changes regarding collaborative health care teams. [ABSTRACT FROM AUTHOR]

A number of ‘food scares’ over the past decade in Europe have generated considerable debate about public understandings of food risk, and the extent to which such understandings impact on decision making. This paper reports on a focus group study of how UK consumers discuss choosing safe food. Strategies for making food choices were, in general, characterised by confidence rather than anxiety. Although concerned in an abstract way with the safety of food and how it was monitored, ‘risk’ and ‘safety’ were rarely the primary discursive framework used for justifying food choices. Other discourses, such as health, naturalness, economy and convenience, competed with, overlapped with or were legitimated by that of ‘risk’. However, everyday decision making was presented as a routine endeavour, aided by a number of ‘short cuts’ or rules of thumb for establishing food choices as routine and unremarkable. These short cuts divided safe from risky categories of food, but also divided preferred from despised foodstuffs in relation to other food discourses. Rules of thumb provided useful rhetorical devices for routinising accounts of food choice. In practice, however, rules of thumb are reported as being utilised in complex and contingent ways. They thus provide a sophisticated bulwark against the uncertainties of food risks when events (such as the media concern over BSE) threaten everyday trust in routine decisions. [ABSTRACT FROM AUTHOR]

Multiple regression analysis was used to determine the longitudinal stability of the structural relationships between the predisposing, enabling, and illness-morbidity characteristics of the population-at-risk and measures of health services utilization. The structural coefficients estimated from the 1971, 1972, and 1973 Health Interview Surveys were examined using the Relative Instability Ratio (RIR) presented in this paper. The RIR values indicate that—except for age, family size, occupation, and family income—all the predisposing, enabling, and illness-morbidity characteristics produce unstable structural relationships. In addition, a negative monotonic relationship was found between the temporal ordering of the groups of characteristics and their ability to produce stable structural relationships. These results demonstrate the need for entrepreneurial health manpower projection techniques and abstract academic explanatory models of health services utilization to become dynamic, rather than remaining in their present static states. [ABSTRACT FROM AUTHOR]