International social work research and health inequalities - 1

Malcolm Payne
Director, Psycho-social and Spiritual Care, St Christopher’s Hospice 51-59 Lawrie Park Road, Sydenham, London SE26 6DZ. Telephone: 020 8768 4500; Email: The international definition of social work (IFSW, 2000) claims that social justice is fundamental to it. Therefore, we might assume that health inequalities, which are widely recognised internationally, would also be a focus of social work and also of social work research. That this is not so arises from: the varying role of social work and therefore its research in national welfare regimes, and the consequences for international research; the complex relationship between social work and healthcare; weaknesses in social work research. I argue that for social work research to tackle health inequalities requires a new agenda in social work research and a structure and policy for initiating and developing research.

National and international social work
National welfare regimes and international scholarship on social work Social work is not the same activity and profession everywhere. In any country, it is structured as part of that country’s ‘welfare regime’, a term that I have adapted from the work of Esping-Andersen (1990). He analyses how different countries provide welfare according to the way in which roles of the state and the market connect to create a particular pattern of provision. This provides a set of social assumptions that form how the welfare services are organised. Social work, as part of those services, is divided differently in every country, to fit that country’s social assumptions and welfare regime. It originated in Western welfare regimes and is primarily Western. However, it has a worldwide influence and is present in many, if not all, societies, but in different forms. There is a range of ‘social professions’, occupational groups that operate in the territory of responses to identified social issues. The welfare regime responds to administrative, government and political structures, legal constraints and cultural and social expectations. To understand social work in any country, it is necessary to have an understanding of its position, structurally, ideologically and politically, in the welfare regime of that country. This is a legitimate part of social work research, but the main focus of this paper in on research that examines social work practice rather than the organisation, provisions and people served of social services. Social work is connected to or plays a part in different aspects of welfare provision in different regimes. Where social work plays a significant role and where it is excluded from major involvement affects what social work is in that welfare regime. In some countries, for example Denmark, it is part of or responsible for social security provision. In the UK, significant aspects of social work are incorporated into

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healthcare, child and family social work is part of local government education provision and social workers may be found in many other aspects of social welfare provision and in agencies where social work is a dominant professional group. The limitations of an international perspective in social work may be seen in its literature. The (British) Blackwell Encyclopaedia of Social Work (Davies, 2000) does not mention international social work, but lists five articles on ‘transnational issues’: European perspectives on social work, globalisation and social work, intercountry adoption, race and racism in social work and social work with refugees. The (American) Encyclopedia of Social Work (Edwards, 1995) is a much bigger production and contains three articles with ‘international’ in the title. Midgley (1995) writes about comparative research on social welfare services and social policy research, Healy (1995) on organisations in international work, focusing successively on United Nations organisations, American government agencies and international social welfare organisations and Hokenstad and Kendall (1995) write about international social work education activities. A number of publishing activities indicate the presence of international connections in social work. Individual texts, for example Midgley (1997), and several series comparing social welfare systems have been published. Examples are series published by Greenwood Press, edited by Elliott, Mayadas and Watts (Watts et al, 1995; Mayadas et al, 1997), IFSW by Tan and colleagues (Tan and Envall, nd; Tan and Dodds, 2002), and various British texts edited by Shardlow and associates (Adams et al, 2000, Adams et al, 2001; Shardlow and Payne, 1998), focusing on Europe. Journals called International Social Work, Community Development Journal, Social Development Issues and Global Social Development publish a great deal of material about transnational projects and activities in social work, and descriptions of activities in single countries with commentary on their relevance and interest for international audiences. Regional journals are well-established, such as the Asia-Pacific Journal of Social Work, the European Journal of Social Work, the Journal of Social Development in Africa and Nordisk Social Arbied (Nordic Social Work). Many other journals occasionally publish comparative article, material based in countries other than that of the country of publication and the journal Social Work Abstracts recognises a number of core international journals, mostly published in the USA, but including the British and Indian journals of social work. Examining the literature discloses a number of points about social work knowledge production: it is often regional in character, for example associated with Africa, American, Asian, European and Nordic regions; it is comparative, being mainly concerned with comparisons at a fairly high level of generality between welfare regimes within which social work is practised in different countries; it often relies on contacts between editors and writers through international organisations or projects. The development of international knowledge in social work There is, however, a significant history of international work and knowledge development in social work, although this might not be termed ‘research’ in the current social science meaning of the term. This history originated at the time of the

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foundation of social work in the late 19th century. It emerged from experiments in different countries responding to urbanisation; some of these, primarily the settlements, the charity organisation (COS) movement and the Elberfeld system of community visiting were internationally influential (Payne, 2005). There was also an international municipalisation movement (Hietala, 1987), which meant that as social work developments began to be incorporated into local government, there were international visits, conferences and circulation of ideas. For example, when Japanese services began to develop in the early 20th century, they were explicitly based on the COS and Elberfeld models, although they also incorporated indigenous ideas (Takahashi, 1997). Other primarily national developments such as the 19th century French development of services to respond to abandon moral (moral danger) of children had some international involvements (Schafer, 1997), and the work of and Elizabeth Fry on prisons and Josephine Butler on women (van Drenth and de Haan, 1999; Jordan, 2001). This international exchange of ideas was reflected in the influence of psychodynamic ideas on social work from the 1920s onwards, the impact of the mental hygiene and eugenics movements of the 1920s and ‘30s and the emergence of the child guidance movement and psychiatric social work in the 1930s. It was cemented by the international conferences on social work starting in 1929, and by Alice Salomon’s (1937) international research on provision of social work education, which was probably the first major international comparative survey relevant to social work. These developments were interrupted by the second world war, and the international organisations restarted their activities. This accounts of them derives form Payne (2006) There are three main ones, which continue in existence today: International Association of Schools of Social Work (on social work education); the International Council on Social Welfare (representing agencies and primarily voluntary or non-governmental agencies); and the International Federation of Social Workers (a grouping of national professional associations of social workers). Although of varying strength and size, and having different purposes, these provide a means of communication through publications, conferences and joint projects of various kinds. More recently, specialised bodies have developed, for example the Inter-University Consortium on International Social Development. There are three other forms of international activity relevant to social work: International non-governmental organisations (INGOs). Examples are international charities and welfare groups like the International Red Cross or Crescent, Save the Children, Caritas, and Médicin Sans Frontiéres. These provide welfare services for people who are crossing borders, such as refugees, and development activities or welfare services in emergencies. Although these are not conventional ‘social work’ as it is known in Western countries, these organisations represent international commitments to welfare in various ways. Governmental and intergovernmental activities. Examples are the provision of aid and joint projects such as the many European programmes which encourage shared training, research and other transfer of expertise across the European Union and, more widely, with the eastern European countries and the states of the former USSR. Similar schemes exist more widely, for example between the

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USA and Latin American and Pacific nations. An example is the Ecspress project of the European associations to create a ‘thematic network of the social professions’ in the 1990s (FHS Koblenz, 1999) International organisations. Examples are the various United Nations agencies. In this context, shared policies are represented in various UN conventions, such as that on children. Many nations become signatories to these. They represent policy and ideological objectives and markers against which local policies are sometimes measured. These different forms of organisations allow for international interchange of ideas and to some extent of personnel. After the war, there was a new international order in social work, since the United Nations became the instrument of the policy of the USA to advance social work as a way of promoting democratic government in countries devastated by the war (Kendall, 1978). Although this was controversial from time to time and in some countries (see for example Satka, 1995, on Finland), the main mode of American social work, social casework and research and literature on it, became influential internationally. For example texts by Biestek (1957), Hollis (1964) and Perlman (1957) were widely used in Western countries. Welfare states began to emerge as a mechanism of welfare provision, which included social work to some degree, in Europe (Sipilä, 1997). Also, the colonial powers, particularly the UK, began to develop community work as a form of social development as they moved towards giving independence to colonies (Yimam, 1990). This in turn influenced the development of community work in the UK and more widely, as colonial administrators returned to the UK to work, and training was supplied in the UK to colonial workers. For example, Batten (1967) wrote texts for colonial social development work, using his experience also to contribute to general theory and practice texts on community work. During the 1960s, social policy studies in the UK began to have a comparative element (Rodgers, 1968). This had an influence on social work, since it works on many of the issues that social policy focuses on. This comparative focus has developed and recently, in a significant text, Clasen (2003) comments: It is often said that social policy can no longer be studied without a comparative perspective. Mature welfare states are undergoing similar socio-economic trends, facing common challenges, and tend to respond to social problems such as unemployment or poverty in fairly similar ways. (Clasen, 2003: 577). A common approach to this is exemplified by an extensive series of texts, edited by Dixon and colleagues (e.g. Dixon and Scheurell, 1989), containing accounts of the national approach to the main social policy areas. A similar approach has been taken up in social work, and some examples were discussed above. As colonial countries became independent, they began to create social welfare services, often based on the models of the former parent countries. The international organisations in social work continued their development by incorporating these countries into their membership, and during the 1960s and ’70 focused on social

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development alongside and began to establish activities in the international social welfare. For example, the International Association of Schools of Social Work received grants to support work on family planning during the 1960s and ‘70s (Oettinger and Stansbury, 1972; IASSW, 1974), and on women’s roles in developing countries during the 1980s (Yasas and Mehta, 1990). These programmes reflected the interests of people who were influential in the Association at the relevant times and the availability of grant aid from international foundations or the UN. Recent research has demonstrated more ambition than simple country comparisons or explorations. Two significant examples are: studies of child protection practice in different European systems, among other methods using idealised case studies to enable workers to explore different approaches to similar cases (Baistow et al, 1995); studies of carers experiences from different European countries using narrative methodologies (Chamberlayne and King, 2000; Chamberlayne, et al, 1999; Chamberlayne et al, 2004). Such studies as these are particularly important because they demonstrate methodologies that can compare different practice approaches and service user and carer experiences, rather than focusing on structural or organisational issues. Another approach to comparative work has been to study similar social work methods in different countries. A pioneer study was the collection of studies of the task-centred model of practice collected in the 1970s by the originators of the model, Reid and Epstein (1972). More recently, the Personal Social Services Research Unit, the originators of the use of American case management as a practice technique in community care services, called care management in the UK, have continued to collect and publish studies of similar methods across the world (Challis et al, 1994), and ‘community social work’ deriving from British social work innovations of the 1980s, was applied and researched in the USA, involving UK originators of many of the ideas (Adams and Nelson, 1995). In addition, theoretical or practice ideas generate publications that juxtapose work in different settings, often arising from conferences. Recent examples include the work on reflection as a means of developing practice (Fook and Napier, 2001; Gould and Baldwin, 2004) and on social construction methods in social work (Jokinen et al, 1999; Hall, et al, 2003). These studies demonstrate that often the originators and promoters of methods applied in a particular country will eventually seek to develop them in other regimes internationally, building up a research profile for their innovation, and that innovative ideas stimulate international responses, with empirical research arising from them. This will not be a surprise to people familiar with the processes of building an academic career and research record, since international impact and comparison is an important marker of the credibility of an innovation. It also illustrates that a concept that is attractive in one welfare regime is likely to be attractive in similar regimes, for the same reasons that Clasen, above, described in relation to social policy research: many developed countries face similar problems, are part of a global network of ideas, and experiment with similar political and social responses.

Social work’s relationship with healthcare and health inequalities
The variation in organisation of social work within different welfare regimes affects the relationship between social work and healthcare, and therefore between the prime

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focus on concern on health inequalities. While in many European regimes, social work has an important role in healthcare, and this is true in the UK, it is often not a primary focus of the service. The recent history of social work in the UK serves to illustrate the point. From the 1970s, social work was primarily organised through the social services departments of local authorities, and healthcare social workers were usually seconded to healthcare settings, remaining in local government employment. The New Labour government in power from 1997 has progressively reconstructed these arrangements, so that social work with children and families has been incorporated into children and families divisions of the local education authority and central government responsibility transferred to the Department for Education and Skills from the Department of Health. Social care services for adults are increasingly organised in joint administrative structures with healthcare organisations, themselves frequently reorganised. The responsible government department continues to be the department of Health. The situation is different in Scotland, which has always had a different set of responsibilities in local government social work departments, including criminal justice, which in Britain has been largely the responsibility of a separate probation service, which itself has been reorganised as part of the National Offender Management Service. Social workers engaged with and specialising in healthcare specialties, such as renal, forensic or palliative care, where there are considerable social implications of healthcare interventions with patients, are often closely integrated with healthcare multiprofessional teams. However, except in the voluntary sector, for example, in voluntary sector hospices, social workers have usually not been employed in healthcare organisations. Their conception of their practice is therefore not well understood, and healthcare organisations have not been accustomed to focusing on social objectives. Health inequalities, on the other hand, have often been regarded by government as primarily matters of macro-level interventions in the public health arena. The government has given high priority to tackling health inequalities in its programme for Action (DH, 2003). Four long-term objectives have been set: improvements in early years support for children and families; improved social housing and reduced fuel poverty among vulnerable populations; improved educational attainment and skills development among disadvantaged populations; improved access to public services in disadvantaged communities in urban and rural areas; and reduced unemployment, and improved income among the poorest. A 2010 target has been set for a number of specific interventions among disadvantaged groups that are considered likely to have an impact: reducing smoking in manual social groups; preventing and managing other risks for coronary heart disease and cancer such as poor diet and obesity, physical inactivity and hypertension through effective primary care and public health interventions – especially targeting the over-50s; improving housing quality by tackling cold and dampness, and reducing accidents at home and on the road;

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improving the quality and accessibility of antenatal care and early years support in disadvantaged areas; reducing smoking and improving nutrition in pregnancy and early years; preventing teenage pregnancy and supporting teenage parents; improving housing conditions for children in disadvantaged areas. (DH, 2003: 4-5) The Wanless report (2004) on effective public health spending focuses on similarly high-level targets. The Programme document claims: ‘To reduce health inequalities and achieve the targets will require us to improve the health of the poorest 30–40 per cent of the population where the greatest burden of disease exists. Nor does this Programme for Action exclude assisting all groups in society from improving health. Our intention is to improve the health of the poorest fastest.’ (DH, 2003: 4). While social workers might be involved in all this at a local level, and some of the disadvantaged groups that are the main focus of action are likely also to be users of social work services, most interventions are not likely to call on social work as a primary mode of intervention. Support for children in early years, help in improving housing, and supporting teenage parents are the most likely to be relevant to social work. This, while it is possible to identify possible social work roles in the UK government’s strategies for tackling health inequalities, the social work profession is unlikely to be in a structural position to make much contribution; moreover its practice is unlikely to be relevant to the major focus of government action.

Social work research
Social work research has been in a weak position. Two recent publications from the Social Care Institute for Excellence, which is given the task of developing social work’s knowledge base in the UK, provide examples of poor funding. Shaw et al (2004) show that the Economic and Social Research Council has shown little recognition of the need to develop the social work knowledge base, although this is likely to have been because of the application of broader social science priorities to social work, which has until recently not been differentiated as a discipline by the ESRC, and Marsh and Fisher (2005) show that finance and administrative support for developing the social work and social care practice knowledge has been significantly lacking compared with similar areas of healthcare, such as primary care, and in government research funding in general. Internationally, there have been claims from the proponents of producing a stronger evidence base for practice (Kirk and Reid, 2002; Sheldon and Chilvers, 2000; Thyer and Kazi, 2004) that social work has not achieved a significant base of evidence for practice. There have been many positive studies, there is evidence for particular interventions and for the role of social work in the constellation of health and social care services generally. This position is controversial, since it represents a focus on positivist empirical view of research that, with its full implications, not all would accept (Webb, 2001, 2002). Moreover, the critique of social work on these grounds is not restricted to it, but is also applied to medicine, which generally has a more robust empirical knowledge base (Gibbs and Gambrill, 2002). It appears that this debate is mainly a conflict between academic and practitioner interest groups in both (and other) fields. However, it does reflect the reality that social work is a relatively small

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field in relation to healthcare, and has not had the academic and personnel resources and research investment to develop a significant research base rapidly. Another factor that is relevant is the political position of social work as a profession. Social work has historically played a role in the maintenance of a moral social order. This was explicit in its early days, when it supported the management of potentially restive poor people through the Poor Law and the Charity Organisation Societies. However, this role continues as a social expectation in the many assessment and reporting roles that social workers have in the societies in which they operate to (Payne, 1999), and often in the views of service users. This conception of social work emphasises its role in maintaining a social order on behalf of powerful elites in society, rather than in achieving social change on behalf of the oppressed. Taking this view implies that empirical analysis of therapeutic of social outcomes is not relevant to the achievement of the objectives that social work is set in political and social debate. It might be argued that this is one of the reasons that practitioners do not seek to achieve empirical outcomes. The supporters of evidence-based practice argue this as strongly, as those who have doubts about the radical potential of social work.

Discussion and conclusion
I started this paper with three reasons for the failure of international social work research to contribute to the reduction of health inequalities. I have argued, first, that international research has not been a strong element of social work knowledge production, and that the main focus has been on comparative work on systems of social service provision, rather than an examination of the potential for social work intervention in health inequalities, or in anything else. Where international research has developed, I suggested that it is regionally focused, and based on existing academic or organisational interchange. Where significant international research projects have developed, there has been funding for projects based on one of these structures by government, inter-governmental or international organisations. Much of the research on issues related to social work have been comparative studies of structures and systems of personal social services provision or user experiences, rather than research about social work itself. While comparative work has the potential to contribute to a policy understanding of the potential role of social services in combating health inequalities, and about barriers to, opportunities for and inadequacies in is contribution it does not say anything about how social work practice might intervene. Social work has a variable and marginal role in the main focus of work on health inequalities, which suggests that its professional commitment to social justice has not been played out in this field. I suggest this is mainly because this ideological commitment is not always foremost in the political and social debate about the role of social work, which forms the role allocated to practitioners in social services systems. While social workers primarily work with deprived groups, and these typically also suffer from the effects of health inequalities, social work practice has not been focused on health inequalities, or the health consequences of deprivation and social inequality. Concern has been expressed in the context of influencing policy development, rather than intervention. In general, social work has had a weak empirical research base, and the most developed area of international research has been on comparative systems analysis rather than on analysis of social work interventions that might be relevant to health inequalities. The most extensive work

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has been done on poverty in relation to population control or family planning, and on the role of women, in social development work in the southern hemisphere. Responding to this scenario, the ESRC seminar series seems to have a number of options to achieve progress in a commitment to address health inequalities through social work and social work research. Researchable social work interventions - In discussing the UK government’s policy objectives in tackling health inequalities, I identified a number of governmenttargeted population groups and social issues where social workers are potentially involved: early years children, people with poor housing leading to poor health outcomes and teenage parents. It may also be relevant to consider smoking, obesity and alcohol and drug misuse as healthcare priorities that have considerable implications for health inequalities. Other governments will have similar objectives. Governments in the southern hemisphere may have objectives around village and community development and women’s oppression that might also be susceptible to group and community interventions in social development. It should be possible to identify actual and potential interventions and research their impact on health inequalities, possibly through robust experimental or random controlled trial research, since many control communities will be available who are not receiving social work interventions. One of the advantages of the weakness of social work research funding is that interventions will almost inevitably be innovatory. Structural requirements and funding - Organisational structures have been required to achieve viable international interventions and research. The special interest group is a potential structure for this purpose, but is likely also to require local partners and government or inter-governmental funding to achieve successful outcomes. Methodological development - Most international research relevant to social work has been comparative work on systems, or evaluation or developmental activity connected to government or international agency objectives. Much of it has mainly been concerned with service structures and political objectives. However there has been innovative work using narrative, social construction and groupwork among professionals to explore different social and service conceptions. To achieve significant results, it will be necessary to move beyond merely comparing service systems at a high level of organisation. It will be more important to understand the experience of interventions and interactions in the perception of service users and in the reality of daily interventions, if the impact of social work on health inequalities is to be examined. However, social work has a potential, which is hidden in the ambiguities of the profession. It seeks to make a difference at the social level, by intervening in the personal and local. It makes the political personal, and hopes thereby to make the personal political. Doing something about health inequalities requires personal and local interventions. Perhaps the failing of much of the effort to deal with health inequalities is that they are only identifiable at the level of a large population, while they are created by processes that are not well understood at the level of the personal and local. Social work, therefore, has the potential to make a different impact to that of many other interventions in health inequality at the population level. Research will certainly be needed to demonstrate the possibilities of such a contribution.

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