Marie Østergaard Møller Associate Professor, PhD.

1. www.categorization.dk TARGETING HEALTH CARE THROUGH PREVENTIVE WORK - A study of the impact of social distance on professionals’ judgments of children and families’ need of health improvements. Introduction It is widely recognized that health care is in a state of crisis. Increased public spending and a decline in support towards poor-resourced people dominate as standard explanations. In Denmark, a welfare state with universal health care, the crisis has led to an adjustment of the universal health care access. The political response has been to target health services to ‘those in need of special care’ through a more intense focus on prevention. The idea is to prevent illness instead of curing it. I study the impact of these new rules on the frontline level where home nurses, pedagogues and teachers interact with children and their families. A study shows that frontline workers think differently about whom to prevent from what, when and why. The degree of social distance as well as professional norms explain part of the variation in worries towards children and families, but the impact of collective orientation, tolerance and aversion remain unclear. Policy problem ”Most children in Denmark grow up in good and secure environments. They have parents, who support them throughout their childhood. They get emotional support and care. Everyday life is in control. The children learn how to become independent individuals and responsible citizens. They have a good childhood. However, some children are not so lucky. They do not get the necessary support from home. There is not enough care. Everyday life is not in control. There are no boundaries. Maybe because parents are fighting their own problems, overshadowing the problems of their children. Maybe the parents do not have the necessary resources to raise and support their child. Many of these children growing up under such difficult circumstances, manage to cope anyway. The outcome is not given beforehand. But these children have an enhanced risk of developing problems, reducing their chances of a good life.” The Danish Government, Equal Oppertunities, 2007 Marie Østergaard Møller Associate Professor, PhD.

2. Hypothesis: Preventive reasoning demands professionals to react on ‘hunches’ of deviance, because no symptoms of health need are (yet) present. Hence, social categories of deviance such as ‘social distance’ is likely to influence their judgments of children and families’ need of health improvement. Data and design: Interviews with 58 Danish home nurses, pedagogues and teachers who interact with children in 8 school districts within 4 municipalities. The interviews are designed to facilitate both interpretive analyses and systematic testing of hypothesis by using vignettes varying with respect to a child’s social characteristics. “The analysis suggests that professionals intervene with more corrections of social normality or lifestyles in the cases of social distance” Theoretical approach: Professionals’ judgments are based on different sources of criteria for judging such as formal rules (health Law), doxa (shared organizational knowledge), policy preferences, normality perceptions, professional knowledge (skills and professional identity) and habitus. Marie Østergaard Møller Associate Professor, PhD.

3. SOCIAL DISTANCE, WORRIES AND INTERVENTIONS - Professionals’ reactions to the presented vignettes in terms of judgments of children and families’ need of health improvements. Impact of social distance on professionals’ worry for children and families: Many professionals spontaneously makes the distinction between real or strong worries and minor worries or “keeping-an-eye-on-things”, giving the opportunity to use this distinction (indicated as (+) and + in the tables). An increase in worry is marked with dark blue and the same degree of worries is marked with light blue I start to worry if there are twenty-five candles and the apples are lying in order all facing the same direction in the bowl. If it’s just too orderly. That does not make me safe. It’s just too much control. And then my alarm bells start ringing (Home nurse, NC11). I had a boy once, who really did not fit in. He didn’t have any support from home, his father was not really there, and the mother was dyslexic, and not really interested. She made sure, that he had his fourteen yoghurts with him every day for lunch so he could get his sugar rush. He would come to school, smelling, not haven taken a bath for a long time […] and he just had a hard time in school, because he couldn’t find any friends. (Teacher, TB09). She always comes five minutes before closing time […] Running with the stroller … and well she is actually at home all day. So it has to do with, when you pick up your child in the day-care, then you go give your child a hug, right? And things like that. She doesn’t do that. She just picks up their stuff and says: “now we have to go home” (Pedagogue, PB08). Marie Østergaard Møller Associate Professor, PhD.

4. The power of social context Further questions and analyses • No increase in worries: • Professionals don’t increase their worry with increased social distance when they compare children’s problems to broader social context beyond the concrete workplace, because in these cases children’s perceived deviance is never associated with their own version of ‘health’ and ‘good manners’. • Increase in worries: • Professionals increase their worry with increased social distance when they compare children’s problems to a narrow social social context for example the concrete workplace, because in these cases the children’s perceived deviance is explicitly associated to how they personally practice health and ‘good manners’. The analysis do seem to give some support to the expectations of an impact of social distance on both the degree of worrying and on the tendency to intervene with corrections directed at lifestyles and social norms/normality. However, there are also indications as to other factors being important, supporting the need for further analysis of, in particular, why some professionals’ resist increasing their worry about children when they are exposed to social distance. Out of the 58 interviews, 22 did not increase their worry as social distance increased in the stories (vignettes) and in 4 interviews worries even decreased. Why? Resistance to social distance can be interpreted as a tolerance towards difference. The relation between the professional’s moral agency and the child’s problem determines which social context the child is associated to. The symbolic boundary drawing used by professionals to identify themselves from different kinds of groups, communities and society in general contributes to the interpretation of the child as well as of difference in general. Marie Østergaard Møller Associate Professor, PhD.