C urrent trends in h ealth care are towards an in c re a s in g ly autonomous r o le fo r the consumer in . managing her own h ealth a f f a ir s and m aintaining contact w ith ,. ap p ro p riate services where necessary. In th is co n text, issues of tinder- or n o n -u tilis a tio n assume considerable s ig n ific a n c e fo r consumers and s ervice p ro vid ers a lik e .
1 .5 .1 . The cu rren t emphasis on prevention
A wider conception of h ealth has been adopted by the World H ealth O rgan isation, w ith the wide-sweeping goal of p o s itiv e p h y s ic a l, mental and so cial w ell-b e in g ra th e r than the absence of disease (Townsend, 1974). The notion of preven tive h ealth care is one which aims to ensure th a t c h ild re n reach th e ir f u l l p o te n tia l fo r growth and development. Many fu tu re improvements in h ealth are thought to depend on changes in behaviour of c lie n t groups, 'h e a lth y ' behaviour e n ta ilin g an increase in in d iv id u a l re s p o n s ib ility fo r personal h e alth s ta tu s .
In 1977 th e DHSS, in conjunction w ith the B r itis h Medical A sso ciatio n , issued a c irc u la r to doctors, encouraging them to 'promote s e lf-c a r e and illn e s s management' amongst th e ir p a tie n ts . These recommendations im ply a coming change in the s tru c tu re , o rg an isatio n and philosophy of
CHAPTER 1: The w ider c o n te xt of underusage
1978a). I t is d i f f i c u l t fo r the public to recognise a focus fo r the in te n tio n s of 'p re v en tiv e * medicine and p ro fe s s io n a lly i t is a fa r more d i f f i c u l t concrept’ to tra n s la te in to everyday tasks (McConachie,
1977).
The emphasis on prevention of i l l h e alth has p a rtic u la r s ig n ific a n c e fo r the c h ild h e alth and m a te rn ity services where i t makes up the main focus of care e ffo r ts . - T h e . b e n e fits b o th , in terms of fin a n c ia l savings and m inim ising human s u ffe rin g are w ell a rtic u la te d (BMJ e d it o r ia l, 1976), th e aim / being to ta c k le some of the s o cia l and environmental sources of i l l h ealth ra th e r than i t s expensive consequences.
There are also consequences fo r the consumer ro le ; the n ature of s erv ice p ro visio n and the way in which h ealth c a r e .is presented to the p u b lic . At le a s t two aspects are worthy of mention in r e la tio n to the vo lu n tary take up of care. Consumers are required to take re s p o n s ib ility fo r th e ir own h e a lth , most notably in terms of adopting 'h e a lth ie r ' ways of liv in g which lin k the idea of in d iv id u a l causation and moral fa ilin g s to a person's h ealth s ta tu s . Issues of blame and choice are ra is e d .
The main focus of change has been located in th e in d iv id u a l ra th e r than th e environment, as th is seems to be th e e a s ie s t, cheapest way to b ring re s u lts . Coward <1984) voices some concern about th is narrow focus as do many others; she p o in ts out th a t even though i t is recognised th a t illn e s s and depression have so cial causes, discourses on h e alth s t i l l emphasise the in d iv id u a l body where change can come
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“Health is presented as something which c a lls fo r in d iv id u a l hard work, not so cial s o lu tio n s ."
"In th is way exh o rtatio n s to good h ealth become exh o rtatio n s to take co n tro l of one's l i f e . "
I t can also encourage "blaming the v ic tim " which, i f . i t i s to be avoided, .requires the c a re fu l e valu atio n of fa c to rs responsible fo r i l l h e a lth .,. I t cannot always be assumed th a t c lie n ts have co n tro l over a ll aspects of th e ir liv e s .
Dingwall (1977), amongst o th ers, comments th a t th e re is , " s t i l l no attem pt to change the so cial and p o litic a l-c a u s e s of i l l h e a lth , w ith the blame put fir m ly on th e s u ffe r e r's shoulders". R ig le r (1982) concludes th a t "most h e alth problems are beyond the co n tro l of any in d iv id u a l" ra th e r m atters r e la tin g to economics and s o cia l p o lic y are of most importance. Other commentators go fu rth e r when a r tic u la tin g the assumptions held about medicine and h e a lth , eg Doyal (1983) draws a tte n tio n to the medical emphasis on in d iv id u a l .cau satio n of i l l h ealth as in a p p ro p ria te , biased and preserving of in e q u a lity . She warns of the tendency to blame the v ic tim th a t such a model encourages. I f i l l h ealth can be explained in terms of in d iv id u a l moral f a ilin g s , then the v ic tim s can be blamed fo r what has happened to thems
"'Way of l i f e ' fa c to rs id e n tifie d as c o n trib u tin g to i l l h e alth are in te rp re te d narrowly and s e le c tiv e ly and u s u ally emphasise the in d iv id u a l's own r e s p o n s ib ility ."
Such a ra tio n a le leaves the so cial and p o lit ic a l s tru c tu re s of s o cie ty unchanged and unquestioned.
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The so cial re la tio n s h ip s involved in the pro visio n of h ealth care do not encourage s e lf-r e lia n c e and re s p o n s ib ility . According to Doyal they can appear b u re au c ra tic, h ie ra rc h ic a l and a u th o rita ria n , so th a t p a tie n ts lack autonomy and power w ith in th e system and are subject to p rofessional in te rp re ta tio n s of what they need.
D o y a l's .X 1983) h is to r ic a l account of th e b ir th and development of w e lfa re services in B r ita in shows th a t women were blamed fo r b ringing i l l h ealth on th e ir own c h ild re n , w ith u n san itary h a b its , going out to work, u n su itab le clo thing^ in a p p ro p ria te feeding e tc . Such issues are s t i l l h o tly debated today.'. The s ig n ific a n c e of inadequate and overcrowded housing, below subsistence le v e l wages and women's need to work to su rvive were a ll obscured.
On the one hand, then, th is could lead to th e censure of persons who f a i l to keep h ealth y (d esp ite good advice) and on the other hand i t may lead to b e tte r inform ed, more questioning and d is c rim in a tin g consumers who can make demands on the services ra th e r than merely having th e ir needs served as carers see f i t . Both fe a tu re s are of special importance when considering the key r o le of v o lu n tary uptake in p re v e n ta tiv e care.
1 .5 .2 . Focus on th e c lie n t p erspective
There has been a notable growth in the breadth and prominence of h e alth re la te d research and comment on women's experiences of medical c are, drawing more a tte n tio n and serious co n sid eratio n to th e kinds of problems and issues which a ffe c t women in p a r tic u la r . Special a tte n tio n is given to the form of so cial re la tio n s to be found in the d e liv e ry of care (Hales, 1982 p .2 1 f f ) . Another im portant strand has
CHAPTER Is The w ider c o n te xt of underusage
been th e research based commentaries on motherhood as experienced today where th e p o lit ic a l, s o cia l and moral im p lic a tio n s are explored (Graham, 1984; O akley, 1979; Oakley, 1980; Comer, 1974). A ll have c o n trib u ted to a concern w ith takin g s e rio u s ly the p ersp ectives and p a rtic u la r problems of women. 4
1 .5 .2 .1 . Growing ap p reciatio n of' women's concerns
Research and commentaries committed to th e - in te re s ts of women draw a tte n tio n to fe a tu re s of the s o cia l world which are regarded as d e le te rio u s to th e ir w e lfa re . For in stan ce, mothers' r e s p o n s ib ility fo r the successful development of c h ild re n has been seen as over—emphasised in recent work.
In d iv id u a l mothers are seen as in c re a s in g ly being held resp o n sib le fo r the w elfare of th e ir c h ild re n , w ith concepts such as m aternal d e p riva tio n being commonly invoked to exp lain a wide range of c h ild re n 's problems (R u tter 1972). Mothering and how th is should be c a rrie d out has been the focus of a wide range of research and comment whereby;
"no other a re a ...h a s had so much a tte n tio n .. . or exposed to the in te rfe re n c e of s e lf s ty le d experts" (Comer
1974)
In h is review of research on mothers, S chaffer (1977) draws a s im ila r conclusion, th a t i t has involved too exclu sive a focus on th e bond w ith the mother.
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The presumed in e v it a b ilit y of c h ild re a rin g as being th e n a tu ra l re s p o n s ib ility of th e b io lo g ic a l mother has been questioned by many w rite rs . However, th e work of Bowlby (1947 and 1969) is s t i l l id e n tifie d as having an im portant and d etrim en tal in flu e n c e on conceptions, of good m othering, d esp ite h is assertio n s having been h e a v ily c r it ic is e d and d is c re d ite d . Issues of over and under mothering are s t i l l being.measured and p re s c rip tio n s a rriv e d a t. As a re s u lt Comer (1974) fe e ls th a t the r e s p o n s ib ility fo r mothers remains awesome, her research shows how delinquency is s t i l l p o p u larly a ttrib u te d to mothers who want to work outside th e home. They are regarded as 'c o ld , s e lfis h and d e v ia n t', w h ils t other fa c to rs are overlooked.
1 .5 .2 .2 . Features of provision
C ertain fe a tu re s of medical provision and care have been id e n tifie d as e x e rtin g a d e le te rio u s in flu e n ce on women's experiences of h ealth care. Doyal (1983) Mednick (1975) and Oakley (1980), draw a tte n tio n to the ways in which women are demeaned and denigrated w ith in modern medical ideology and p ra c tic e , by having s te re o ty p ic a l a ttr ib u te s accorded to them. They were considered to be possessed by a ffe c t? incapable o f ra tio n a l or a n a ly tic thought, not worth the tim e and energy req u ired fo r good p a tie n t care and f i n a l ly scheming and o p p o rtu n is tic (Doyal 1983).
In medical encounters, both 'common sense t a l k ' and te c h n ic a lis a tio n were found to undermine women’ s confidence and encourage a passive p a tie n t r o le . Over 90% of O akley's (1980) sample reported i r r i t a t i o n
CHAPTER l i The w ider c o n te x t o f underusage
to be the ty p ic a l medical re ac tio n to th e ir mentioning th e ir other o b lig a tio n s and i t was w id ely reported th a t they were not lis te n e d to but merely ty p ifie d as n a tu ra lly maternal and- as such had s te re o ty p ic a l .mothering concerns a ttrib u te d to them and taken fo r granted.
Such analyses s tre s s . the growing awareness th a t medical p ra c tic e fu n ctio n s as a* s o cial fo rc e helping to shape the options' and ro le s a v a ila b le to those who seek card. ,
The p ro fe s s io n a l!s a tio n of m atern ity care in general from th is p ersp ective is regarded as having removed the cap acity fo r autonomous co n tro l from women to medical exp erts. (Oakley 1980? Bardwick 1980; Raymond 1979; Dingw all 1977).
Dingwall (1977) review s the many studies which have drawn a tte n tio n to th is d is tin c tiv e fe a tu re of the contemporary approach to parenthood: the re lia n c e on s p e c ia lis t knowledge gleaned from outside the fa m ily co n text. This is provided through contact w ith s o c ia lly appointed experts and the p r o life r a tio n of books, magazines, le a f le t s , TV and ra d io . The guidance contains s c ie n tific th e o rie s drawn from em p irical research on p a tte rn s of c h ild re a rin g but also most im p o rta n tly a d is t illa t io n of c u ltu ra l understandings about th e natu re and management of c h ild re n .
H is to r ic a lly , women have had lim ite d access to s c ie n t if ic knowledge on