Contents lists available at ScienceDirect
Children and Youth Services Review
journal homepage: www.elsevier.com/locate/childyouthTrust as an analytical concept for the study of welfare programmes to reduce
child health disparities: The case of a Swedish postnatal home visiting
programme
Cecilia Franzén
a,⁎, Eva-Lotta Nilsson
b, Johan R. Norberg
c, Tomas Peterson
c a Faculty of Odontology, Malmö University, SE-205 06 Malmö, Swedenb Faculty of Health and Society, Malmö University, SE-205 06 Malmö, Sweden c Faculty of Education and Society, Malmö University, SE-205 06 Malmö, Sweden
A B S T R A C T
The aim of this article is to outline a theoretical framework for how the concept of trust can be used as analytical tool for a study of the aim, design, output and societal legitimacy of a Swedish welfare programme conducted to reduce disparities in health and social inequities and to give newborn a positive start in life. This programme, labelled Grow Safely, implies that home visits will be conducted at six occasions at first-time parents by different professionals: child health care nurses, midwifes, dental hygienists and counsellors from the social services. Prior to when the intervention is carried out, the involved professionals in the programme will be participating in training in order to increase the possibility that the home visits will be carried out in similar ways and be followed the same manual throughout the programme.
The welfare programme will be based on relationships on different levels: between professionals and parents, between different professionals, between profes-sionals and managers, and between organisations. Trust is believed to be of significance for the development of relationships as well as for the social legitimacy of the implantation of welfare programmes. Therefore, our ambition is to embrace a broad perspective on trust, combining insights from a variety of research traditions and analyses on macro, meso and micro levels in the outline a model for how the concept of trust can be used as an analytical tool for studying welfare programmes like Grow Safely. We argue for that the model can capture the significance of trust at different levels: individual, professional, organisational and societal levels as well as interplays between these levels, and consequently be useful in to analyse implementations of welfare programmes.
1. Introduction
Like in many countries, one of Sweden’s political undertakings is a competent welfare system that contributes to the good health and well- being of its citizens. In line with this, in September 2019, the welfare programme called Grow Safely was initiated in the region of Scania in the southern part of Sweden. The programme was initiated and fi-nanced by politicians at the national level and supported by politicians at the regional level. Grow Safely is an extended home-visiting pro-gramme for first-time parents. In Sweden, the child health service offers all families a regular health check-up programme, including two home visits – one soon after the birth and one when the infant is 8 months old. However, with Grow Safely, families are offered a total of six home visits during the child’s first 15 months. During these visits, the families will meet professionals from child healthcare, maternal healthcare, dental care and social services. The overarching aim of Grow Safely is to promote children’s health and provide everyone with an equal start in life. The project is universal and open to all first-time parents.
The welfare programme involves a web of relationships between organisations, professionals and parents, individuals from different professions, and between professionals and managers. Trust is deemed important for the development of collaborative behaviour needed in the interactions with the health and social care professionals. Collaborative behaviour is at the foundation of a well-functioning and efficient healthcare system (Ozawa & Sripad, 2013). The development of the legitimacy of interventions initiated from the state within healthcare systems is also important. For example, a state’s funding structure can create financial incentives for healthcare professionals to not act in the best interest of the patients and instead focus on certain treatments to maximise their profit, which can lead to patients’ distrust of not only the professionals but also the healthcare system in general and the state (Gilson, 2003). Therefore, the aim of this article is to outline a theo-retical framework for how the concept of trust can be used as an ana-lytical tool to study the aim, design, output and societal legitimacy of child welfare programmes. The starting point of this paper is with Grow Safely, but the theoretical framework is relevant to other welfare
https://doi.org/10.1016/j.childyouth.2020.105472
Received 7 May 2020; Received in revised form 10 September 2020; Accepted 10 September 2020
⁎Corresponding author.
E-mail addresses: cecilia.franzen@mau.se (C. Franzén), eva-lotta.nilsson@mau.se (E.-L. Nilsson), johan.norberg@mau.se (J.R. Norberg), tomas.peterson@mau.se (T. Peterson).
Available online 18 September 2020
0190-7409/ © 2020 The Authors. Published by Elsevier Ltd. This is an open access article under the CC BY license (http://creativecommons.org/licenses/BY/4.0/).
programmes as well.
The first section of this paper briefly presents the Grow Safely programme. In the next sections, we describe and argue for our theo-retical framework and for the use of the concept of trust as an analytical tool to study the aim, design, output and societal legitimacy of not only the welfare programme in question but also welfare programmes in general.
2. The background and design of Grow Safely
Extensive research has shown that human health and welfare are unequally distributed in society. Sweden is no exception. Even though the health of Sweden’s population can generally be considered as good, it is still unequally distributed among the population, as is the utilisa-tion of care (Ivert et al., 2013). In Sweden, the average life expectancy for persons with post-secondary education is more than five years longer than for those with pre-secondary education (SOU, 2016). In Malmö – Sweden’s third largest city and the largest city in Scania, where Grow Safely takes place – the difference in life expectancy in areas of high, respectively low socioeconomic status, is four and a half years for women and five and a half years for men (Malmö city council, 2013). Moreover, a study shows that individuals’ access to a regular doctor – which is preferable to a regular provider, as it gives better access to healthcare – differs between the municipalities in Scania (Lindström et al., 2006). One aim for child healthcare in Sweden is that it should follow the health and life situation of children to promote equal health (National Board of Health and Welfare, 2014). Grow Safely was created against this background. The aim of the programme is to reduce disparities in health and social inequity in Scania and to give all newborns a positive start in life.
Grow Safely was inspired by a programme of extended home visits conducted by a healthcare centre in Rinkeby, a suburb of Stockholm. In Rinkeby, first-time parents were offered six home visits during the child’s first 15 months (Burström et al., 2017). Both nurses from the child health services and counsellors from the social services conducted the home visits. Results from the extended home-visiting programme included, for example, better vaccination coverage and less hospital visits among the children who participated in the intervention (Marttila et al., 2015). The experiences of the families that participated in the programme were generally positive. They stated that the home visits gave them the opportunity to develop valuable relationships with the child healthcare professionals and the social services. Moreover, the collaboration between the two professions worked well, which is not always the case when professionals with different professional back-grounds are required to work together (see e.g. Fournier, 2000; Franzén, 2020; Frost, Robinson, & Anning, 2005; Huxman & Vangen, 2005; Powell & Davies, 2012).
The model for Grow Safely is presented in Table 1. The participation in the programme extends over the child’s first 15 months, with the
entire project planned to continue for two years.
The home visits will be carried out by child healthcare nurses who will be accompanied once with a midwife, once with a dental hygienist or a dental nurse, and four times with a counsellor from social services. Prior to the intervention, the staff participating in the programme will undergo training to increase the possibility that the home visits will be conducted in a similar manner.
3. The concept of trust in contemporary social science research In recent decades, the research on trust has increased dramatically in the social sciences. It is a concept that is used in a wide variety of different research traditions – from psychology, sociology, political science and economics to philosophy – to understand a wealth of dif-ferent social phenomena.
At the most overarching societal level (macro), theories of trust are used to understand how societies can be formed, developed and made sustainable. Much of human behaviour requires a certain degree of trust between individuals. Without trust in the expertise of professionals, we would be reluctant to seek medical care when we are sick or board an aircraft when we need to travel. Moreover, without trust in monetary systems, we would be wary of making agreements or trading with other people. From this perspective, trust is a prerequisite for social interac-tion between individuals, while lack of trust leads to passivity, disorder and ill-health, or as formulated by Geoffrey Hosking (2014), ‘Routine, unthinking trust is, then, part of the texture of our everyday lives, whether we recognize it or not’ (p. 4).
In sociology, the concept of trust is often used to explain the relation between the individual and society. This can be done either from the point of view of the individual (often through theories of social psy-chology) or as an analysis of how and why society holds together. In early sociology, this way of understanding trust goes back to Durkheim and his concept of social facts, describing how norms and values steer both individuals and the society as a whole (Durkheim, 1982). Trust also reflects power, as in Weber’s theory of legitimacy (Weber, 1978). In modern sociological theory on late modernity and post modernity, trust is discussed as something that exists only between people. It forces itself on the individuals, possesses them and then forms their behaviour and actions (Giddens, 1984; Luhmann, 1979).
In political science, the concept of trust is used to understand and measure the strength and efficiency of political systems. The core of this research is the notion that levels of social trust among individuals in a society are linked to political trust (i.e. civic virtues, democratic values, and attitudes towards politics and public institutions at large). According to this theory, high levels of social trust among individuals tend to be found in effective and well-functioning democratic societies. Conversely, low levels of social trust are found in societies with wide-spread distrust of politicians and public institutions, and high levels of corruption and ‘client–patron’ relationships. The origin of this research can be traced back to pioneers of political science and scholars such as John Locke and Alexis de Tocqueville. In modern times, however, the importance of trust has undergone a renaissance. A vital and broad field of research has been created focusing on trust, social capital and social traps (Putnam, 2002; Rothstein, 2005). In this study, great efforts have been made to understand the mechanisms that can strengthen trust in society and create social bonds between citizens. The significance of such research has not diminished in recent years, given an international political climate characterised by increased political conflicts, distrust of politics and social institutions, and the emergence of populist parties, and similar. (c.f. Eurofound, 2013; European Commission, 2017).
In economics, the concept of trust is used to understand social and economic behaviour. In rational choice and game theory, con-ceptualisations of trust are used to understand how trustworthiness affects decisions and relations in networks, groups, and institutions (Buskens et al., 2018). Among political economists, trust is used to understand the social norms that underlie economic activity (cf. Table 1
The structure of Grow Safely. Home visits offered to all families in Sweden
The extended home-visiting model Grow Safely
Child healthcare nurse Child healthcare nurse Midwife Social
services Dental hygienist Age of child 1–2 weeks X X X 2–3 weeks X X 4 months X X 8 months X X 10 months X X X 15 months X X
Ostrom, 1990). According to Fukuyama (1996), trust is an economic lubricant that can reduce transaction costs between actors, thus pro-moting prosperity and economic growth. In his view, the neoclassical model of ‘economic man’ is not sufficient for explaining human beha-viour and successful market development. A culture of trust is also needed and a capacity for ‘spontaneous sociability’ in society. As em-pirical evidence, Germany, Japan and the United States are countries known for both high levels of trust and of economic success, while southern Italy are an example of a ‘low-trust’ society with limited economic development.
Questions about trust in justice, the legitimacy of justice institu-tions, and people’s commitment to the rule of law are core questions within the field of criminology. Public trust in the legal system is re-quired to ensure normative compliance with the law, which is an im-portant goal of criminal justice policy. Central institutions of justice, such as the police and criminal courts, carry out important functions in society and people’s compliance with the laws and their willingness to cooperate with the police is often discussed in relation to people’s trust in the legal system in general and with the juridical system and police in particular (Boateng, 2018; Bottoms & Tankebe, 2012; Hardy, 2019; Jackson & Bradford, 2010; Jackson & Gau, 2016; Torrente, Gallo, & Oltra, 2017). For example, crime reporting is a complex decision- making process influenced by several different interrelated aspects at the structural, social, situational and individual levels (see e.g. Hardy, 2019). On all levels, trust is a key influential aspect (e.g. Boateng, 2018; Hardy, 2019; Jackson & Gau, 2016; Kääriäinen & Sirén, 2011; Torrente et al., 2017).
In research on public administration and governance, the concept of trust has been given the role of a new form of governance doctrine, which poses a challenge to the prevailing managerial values and ideals that have dominated the management of public administration and organisations in recent decades. This is influenced by the idea of New Public Management that focuses on marketisation, management by objectives, performance indicators and performance monitoring (Hood, 1991). Consequently, organisations have been characterised by em-phasising control, evaluation, and audit, which is well described by Michael Power, who introduced the concept of ‘audit society’ (1997). After the criticism of marketisation, austerity, audits and decreased professional autonomy due to regulations of their work in the public sector, particularly in the fields of education and healthcare, the con-cept of trust has emerged as a new and alternative governance philo-sophy in Sweden as well as in other countries. In Sweden, more trust in management has been emphasised by the Delegation for Trust-Based Public Management to make more use of employee competence and experience and to increase their freedom for action with the aim of higher-quality welfare services for citizens (Bringselius, 2018).
The concept of trust is also common in research on professions. For example, research on healthcare shows that individuals’ trust in health professions can affect the utilisation of medical care, satisfaction with and loyalty to health professionals, adherence to treatments and more (Ozawa & Sripad, 2013). People’s trust in healthcare is both a result of actual personal experiences (interpersonal trust) and of perceptions and views concerning healthcare at the institutional level (institutional trust) (Mohseni & Lindstrom, 2007; van der Schee, de Jong & Groenewegen, 2011). The two types of trust are interrelated. In-dividuals’ trust in a system or an institution is influenced by personal experiences of the healthcare system or representations of the system, such as health professionals (van der Schee et al., 2011). For example, positive contact with a local doctor may increase one’s trust in the health system in general (Misztal, 1996). Conversely, people’s trust in the healthcare system in general can help the development of inter-personal trust between themselves and health professionals, and have an influence on their willingness to visit a healthcare institution (Mohseni & Lindstrom, 2007).
The brief overview shows that the concept of trust is often used in the field of social science at macro, meso and micro levels. Moreover,
although the research on trust derives from different scientific tradi-tions and is conducted from a variety of theoretical points of departure, the view of trust as an analytical concept is strikingly uniform. Trust is seen as a social phenomenon in which actors are willing to rely on other actors, thereby enabling action, efficiency and social cohesion. From a research perspective, this creates opportunities to combine experiences and perspectives from different research traditions and combine dif-ferent levels of analysis. Therefore, our aim is to take a broad per-spective on trust as a theoretical concept and an analytical tool, com-bining insights from a variety of research traditions and analyses on macro, meso and micro levels. In the following section, we outline a theoretical framework for how we operationalise the concept of trust to analyse the programme’s aim, design, output and societal legitimacy. 4. A framework for analysing trust
4.1. What is trust?
Despite many attempts, researchers on trust have not yet been able to agree how the concept should be defined and operationalised. The lack of consensus can partly be explained with reference to different starting points and focus among diverse scientific disciplines (cf. Bachmann & Zaheer, 2006). A common way of discussing trust, how-ever, is to emphasise its relational nature: that trust ultimately is about whether a trusting party (trustor) is willing to rely on actions of another party (trustee). Equally common is to link trust with risk and with ex-pectations for the future. This is because trust inevitably contains an element of hope that someone will act in a certain way – or that a certain event will occur – but simultaneously a risk that the action might not take place (Hosking, 2014). A popular definition of trust that emphasises both this element of risk and a time dimension is provided by Mayer, Davis & Schoorman (1995, p. 702). They define trust as ‘the willingness of a party to be vulnerable to the actions of another party based on the expectation that the other party will perform a particular action important to the trustor, irrespective of the ability to monitor or control that other party’.
This definition is useful. It is an operationalisation of the concept of trust that can be applied in many and different contexts: in analyses of behaviour among peoples and organisations, and in studies of attitudes and values towards political institutions, et cetera. Furthermore, it is a definition that emphasises the fragile and temporary nature of trust – that trust is an attribute of a relation that always must be earned and can easily be lost (cf. Rothstein, 2005).
4.2. How is trust created?
An equally debated question in the literature of research is how trust is created. Why do some individuals and groups inspire a greater degree of trust than others? Why does trust in politicians and public officials vary between countries? A simple answer cannot be given. According to Bringselius (2018), trust is based on one party’s assessment of the other party’s trustworthiness. People’s trust propensity is the result of many factors, such as individuals’ personalities and experiences, and tradi-tions, norms and values in different cultures. In addition, the extensive political science research on social capital, in which trust – or the level of generalised reciprocity in society – is linked to citizens’ active par-ticipation in social networks (Putnam, 1992; 2000) and the design of political systems and welfare institutions (Rothstein, 2005).
According to Mayer et al. (1995), an individual’s trust in another party is based on perceptions about that party’s ability, benevolence and integrity. Ability concerns skills, knowledge and characteristics that enable actors to have influence within specific domains. According to this view, trust is not a universal characteristic, as people’s skills are different and varied. A doctor may be very trustworthy in a medical context, but not necessarily in other matters. Benevolence is the extent to which an actor is believed to do good for a trusting party without
prioritising their own interests. Integrity involves the extent to which an actor adheres to principles that are accepted by others, the con-sistency of the actor’s behaviour and the extent of congruence between the actor’s words and behaviour, that is, to fulfil promised agreements. Bringselius (2018) explains that these three trustworthiness factors are being able to help, daring to help and being willing to help. Therefore, one can say that a one trusts a person or a system to the extent that they believe the other person or the system can, dares to, and will act in the best interest of the person. This view of trust can be applied to three different levels in the analysis of trust: interpersonal, intergroup or inter-organisational (Schoorman, Mayer & Davies, 2007).
Bringselius (2018) argues that ability concerns not only an in-dividual’s competence but also their legal, organisational and compe-tence related prerequisites. In other words, trust is created in the in-teraction between people’s actions and their conditions for action. An empirical analysis of trust should thus combine studies of individuals’ actions with studies of institutional or structural prerequisites for ac-tion, such as financial resources.
5. Trust as analytical tool for analysing Grow safely
This section outlines a model for how the concept of trust can be used as an analytical tool to study Grow Safely and similar welfare programmes. The model is multidisciplinary by combining knowledge, experiences and perspectives from different scientific traditions. More specifically, research about trust first aims to identify which relation-ships in Grow Safely are relevant to study and which questions should form the main research questions. Our aim is not to solely use the three abovementioned trustworthiness factors – ability, benevolence and in-tegrity – but rather to give examples of more overreaching questions (Table 2).
5.1. Clients’ trust in professionals
The micro level refers to relationships between individual actors. In Grow Safely, we find three main relations of trust: clients’ trust in professionals, professionals’ trust in clients, and trust between profes-sionals in multi-professional teams.
The first aspect, clients’ trust in professionals, addresses the issue of clients’ attitudes towards healthcare institutions. The overarching aim of the programme is to promote children’s health and an equal start in life through an extended home visit programme for first-time parents in collaboration with healthcare, dental care and social services. This aim is to be achieved in two ways. Firstly, during the visit, the families participating in the project will be given information and support on issues relating to parenting. Secondly, the programme is intended to promote the roles of nurses, midwives, dental hygienists and social
workers through positive experiences with the participating families, which may help generate a positive attitude towards Swedish welfare institutions in general. The latter aim is particularly important for groups that are underrepresented in Swedish healthcare, such as newly arrived migrants.
In both aspects, the element of trust is believed to be crucial for the clients’ trust in the professionals. First-time parents will maybe not take in information and recommendations unless they perceive the profes-sionals as competent and the home visits as legitimate and positive. Furthermore, interpersonal relations between professionals and clients based on trust may be a prerequisite for the home visits to promote positive attitudes to welfare institutions in general. Therefore, the fa-milies’ trust in the professionals they meet is important because it can influence their satisfaction with the health professionals they will meet later and their adherence to the recommendations of the health pro-fessionals (Pearson & Raeke, 2000). Trust at this level involves the clients’ expectation that the professionals will keep their interests in mind before their own (Schwei et al., 2014).
However, a challenge in creating trustful relationships between professionals and patients or clients in healthcare, dental care and so-cial services is the uneven distribution of power that stems from the professionals’ position as educated experts. Clients and patients often have to rely on the competence of professionals, but they do so from a structurally inferior position, as there often is a knowledge gap. Consequently, it may be difficult for clients to question or impose upon professionals’ judgements (Grimen, 2009). Furthermore, clients are also dependent on professionals’ goodwill, as professionals often act as gatekeepers by controlling patients’ access to the resources and services they may need, such as specialist healthcare services (Grimen, 2009; Hasenfeld, 2010). Therefore, two important empirical questions are how the families perceive the competence of the professionals and to what extent do they trust the professionals to act in their best interest. 5.2. Professionals’ trust in clients
A second dimension of trust at the micro level concerns the pro-fessionals’ relationship with the clients. It is morally desirable that professionals trust the individuals they meet concerning their life his-tories, expressed problems, needs and expectations, as trust is crucial to the development of a respectful relationship. In addition, it facilitates collaboration between professionals and clients. Professionals’ trust in clients also involves treating them as moral agents who can take re-sponsibility for their own choices and actions (Rogers, 2002). These notions of trust are in accordance with an empowerment approach that concerns the promotion of individuals’ health and quality of life through the support of professionals who have to increase or strengthen the individuals’ control over factors that influence their lives. For Table 2
Aspects of trust in the Grow Safely study.
Relations of trust Examples of research questions Micro Level
Clients’ trust in professionals How do the families perceive the professionals who carry out the visits? Do clients trust that the professionals to act in their best interest?
Professionals’ trust in clients Will the professionals trust the parents to be competent enough to take responsibility for their own life and their child’s life and thus treat the parents as autonomous and trustworthy persons?
Trust between professionals in multi-professional teams How are tasks and responsibilities distributed among professionals? How are conflicts or disagreements settled? How is trust among the professionals developed and maintained?
Meso Level
Trust and collaboration between organisations in welfare
programmes How are tasks and responsibilities distributed among organisations? How are conflicts or disagreements settled? How is trust among the organisations developed and maintained? Trust and control of professionals in organisations How will the control of the professionals be designed in a balance between control and trust?
Macro Level
Trust, social capital and legitimacy Can home visits promote trust in welfare institutions and society at large? Is there popular and political support for the endeavours of programmes like Grow Safely?
professionals, such an approach implies that they relinquish their power and trust that people can identify their own problems, find out how these can be solved, and have the capacity to solve them. However, this holds true only when the individuals have relevant knowledge and skills, and support from the professionals. In practice, this means that the professionals work together with individuals and enter into a dia-logue that is characterised by empathic listening and the willingness to understand the others’ view of the world (Tengland, 2008). Such a health promotion approach is in line with the political intention of Grow Safely, which is to contribute to a good start in life for children by promoting the parents’ control over their own and their children’s life circumstances that may have an impact on their children’s health and well-being. This leads to the empirical questions of both how the pro-fessionals who are involved in Grow Safely will perceive the parents and the quality of the relationship between themselves and the parents. Will the professionals trust the parents and believe that they are com-petent enough to take responsibility for their own and their child’s life, and consequently, treat the parents as autonomous persons? Or will they treat the parents as less knowledgeable and competent, and view themselves as professionals who should give parents advice based on their professional expertise? These questions should be asking knowing that to involve parents in decisions means the professionals decrease their power and authority, which can be perceived as undermining their traditional professional role. Therefore, some professionals may struggle with the empowerment approach.
5.3. Trust between professionals in multi-professional teams
A third dimension of trust concerns the relationships between the professionals in the teams that are required to work together within the programme. The idea of multi-professional teams is in line with the WHO recommendation that emphasises the significance of inter-professional collaboration to meet individuals’ health needs and for improved health outcomes (WHO, 2010). However, a prerequisite for the home visits to become positive experiences for new parents lies in the professionals’ capacity to act together in well-functioning groups. This may be a challenge. The core beliefs and experiences of profes-sionals in different fields of expertise can differ (Powell & Davies, 2012). This may lead to conflicts and disagreements concerning how patients and clients should be met, how problems should be solved, and how work tasks should be divided. As a result, demands on profes-sionals to work in teams can lead to them doing boundary work that aims to create and maintain boundaries around desirable work tasks. However, professionals have different possibilities to maintain or to expand their boundaries (Fournier, 2000). In workplaces, there can be power issues between disciplinary groups. For example, in healthcare, physicians have a more dominant position and more influence on work division compared to nurses due to their autonomy in patient care and stronger scientific position (Freidson, 1994; Lipsky, 1980; Powell & Davies, 2012). However, individuals from different professions do not necessarily compete with each other but instead work closely with the aim doing good work (Allen, 1997; Apesoa-Varano, 2013; Carmel, 2006).
Trust is significant for the development of successful interprofes-sional teams (McDonald, Jayasuriya & Harris, 2012; Pullon, 2008). However, trust does not emerge automatically. It has to be developed and earned. Trust in interprofessional teams is based on many factors. Firstly, the professionals need to respect each other. This respect is built on a shared understanding of each other’s roles and competence. Sec-ondly, mutual respect may lead to the development of trust on an in-dividual basis within a team over time (Pullon, 2008). Trust between individuals in workplaces further concerns expectations of each other’s behaviour. This has been emphasised as important for a safe and smooth work environment and for the quality of relationships between individuals: ‘Collegial trust is a form of personal trust that relates to our colleagues and refers to the expectations that they will behave
professionally, work with integrity and do the things they say they are going to do, or the things we can rightfully expect them to do (such as follow established protocols etc)’ (Jackson, 2008, p. 1541).
In the Grow Safely study, collaboration between the professionals is an important area for empirical studies. How are tasks and responsi-bilities distributed between the professionals? How are conflicts or disagreements settled? How, and to what extent, is trust among the professionals developed and maintained?
5.4. Trust and collaboration between organisations in welfare programmes The meso level concerns relationships within and between the three welfare institutions with the task to implement Grow Safely: healthcare, dental care and social services. Internationally, the integration of health and social services is widely recognised as a strategy to develop sus-tainable healthcare systems (Valentijn et al., 2015). However, colla-boration and integration between separate organisations can take many forms and be based on many preconditions. Compared to intra-orga-nisational relations (collaboration between departments within a single organisation), inter-organisational relations are not parts of a common management hierarchy. Therefore, in organisational theory, intra-or-ganisational relations are often characterised as ‘loosely coupled’ and in the form of ‘networks, partnerships, coalitions and strategic alliances of organisations, or as an “ecology” of organisations’ (Axelsson & Axelsson, 2006, p. 76). According to Axelsson and Axelsson, inter-or-ganisational relations in the field of public health can be analysed as a result of two dimensions: vertical and horizontal integration. Vertical integration occurs between organisations on different hierarchical le-vels, that is, with different status or opportunity to exert an influence in the collaboration. Horizontal integration takes place between organisa-tions on the same hierarchical level, that is, between equal parties in terms of power, status and influence (Axelsson & Axelsson, 2006).
For Grow Safely, a close and successful collaboration between the participating organisations is a necessity. However, certain challenges will need to be overcome, such as different organisational objectives, different costs for the required activities, and organisational rules that hamper successful coordination. To achieve successful coordination, the participating organisations must find ways to remove these ob-stacles. When that can happen, the degree of trust between them rises significantly. As mentioned, trust between actors depends on the per-ceptions of the actors’ ability, benevolence and integrity. If one of the organisations does not to deliver on these aspects – if it is primarily motivated by its own financial interests or does not fulfil agreements – this will negatively impact the building of trust (Schoorman et al., 2007).
Trust is preferred over contracts in the management of network of public institutions in welfare programmes. This is because trust is supposed to enable networks of organisations to function effectively, as it can break down barriers that prevent cooperative behaviour and encourage communication and the flow of information, and conse-quently, be the basis for co-operation to achieve common goals. Further, the effectiveness of networks of organisations can in turn in-fluence patients’ trust in professionals by shaping the professionals’ competence and fairness, and the range of services they offer (Gilson, 2003). Therefore, an empirical question is how the relationships and trust between the involved organisations will take form and develop during the implementation of Grow Safely.
5.5. Trust and control of professionals in organisations
A fourth dimension of trust concerns the control and management of welfare institutions. Trust in the relationships between managers and employees is important in all organisations, but of particular sig-nificance in welfare institutions where services are provided by pro-fessionals with considerable discretion to make their own work deci-sions, so-called street-level bureaucrats. The discretion of professionals
means that they have power and control to decide which tasks to per-form and how to perper-form them (Lipsky, 1980). Under these circum-stances, managers have to trust that the professionals will act pro-fessionally and responsibly (Firth-Cozens, 2004). Grow Safely is no exception. The professionals involved in the programme – the mid-wives, the nurses, the dental hygienists and the social workers – have great autonomy to organise the home visits based on their knowledge and skills. This autonomy limits their managers’ control of their work. In general, managers in organisations built around professional activ-ities have economic and administrative responsibility and considerable control over material resources but often limited possibilities to control the professionals’ work. The restricted control is partly due to the professionals’ discretion and party because of the regulations of pro-fessionals’ work and professional norms that direct how their work should be done (Brunsson & Sahlin-Andersson, 2000). In the case of Grow Safely, the managers’ control is further limited by the meetings between the professionals and the families taking place in the families’ home.
The management practices of the professionals’ organisations can be significant for the professionals’ attitudes and practices towards the parents. The trend in the management of healthcare and welfare or-ganisations with a focus on evidence-based national guidelines, quality indicators and performance monitoring have been described as a de-parture from the traditional trust in a profession’s autonomy to set its standards (Cruess, Cruess & Johnston, 2000) and power to decide how to use its expertise in the treatment of the individual patient (Freidson, 1994). In contrast, management practices that are more based on trust will permit professional discretion and the opportunity to involve cli-ents in the problem-solving process in accordance with a client-centred approach (Gilson, 2003). Further, trust-based public management fa-vours increasing the professionals’ freedom for action (Bringselius, 2018). Therefore, an important aspect in the design of Grow Safely is how the management of the programme and professionals within the programme is designed. Will the steering group and the managers in the involved organisations endorse a high level of centralisation, where the professionals’ discretion is limited by unified regulation, guidelines and financial instruments, or will the programme be characterised by de-centralism, where the professionals are given self-determination and freedom of action? In short, how will the control of the professionals within the programme be designed in a balance between control and trust?
5.6. Trust, social capital and societal legitimacy
At the macro level, we draw inspiration from political science and theories on civic trust and its importance for societal efficiency and democracy. With the concept of social capital, Robert D. Putnam has inspired extensive modern research on the relationship between civic trust and well-functioning democratic systems. Putnam's well-known thesis is that civicness and social interaction between citizens are fun-damental for effective and democratic institutions. In general, people’s trust in political institutions is a reflection of their trust in other people at the individual level – and this trust is in turn a result of citizens’ community involvement at the local level, in associations and civil society (Putnam, 1992).
However, in subsequent studies, several researchers have turned the chain of causality: it is well-functioning democracies that promote so-cial capital, and not the other way around. In particular, the Swedish political scientist, Bo Rothstein, has in a number of studies, argued that citizens’ sense of trust and civicness are not primarily a result of local choirs and football clubs but rather by the design of the public in-stitutions and the quality of the welfare services they receive (Rothstein, 1998, 2005). This is important. With regards to Grow Safely, the notion becomes that home visits can have far-reaching social effects in addition to promoting equal health among children. If the home visits are perceived as positive by new parents, this can generate
increased confidence in both welfare institutions in general and – by extension – to society at large. In Sweden, those with limited experi-ences of welfare services and scepticism towards public institutions, Grow Safely can thus increase confidence in the Swedish political system.
But research also shows that levels of trust are diminishing in modern societies (cf. Eurofound, 2013; European Commission, 2017). Sweden is no exception. Grow safely is implemented in a societal cli-mate characterised by increased political conflicts, distrust of politi-cians and social institutions, and the emergence of a strong nationalist and populist party (Fryklund & Saveljeff, 2019). This generates dif-ferent perspectives and new questions regarding to Grow Safely. Will the professionals doing the home visits be met with mistrust and defi-ance from parents? Will decreasing trust in welfare institutions among parents limit the programme’s impact? Will the programme be per-ceived as legitimate in a society marked by increased xenophobia, segregation, and distrust of politicians and public officials? Is there popular and political support for the endeavours of equality and social inclusion that form the very conditions for Grow Safely?
6. Conclusions
Trust is a concept applied in a variety of research traditions. By drawing on different scientific areas, we have described a theoretical framework and demonstrated the relevance of trust in our analysis of the implementation, output and social legitimacy of a Swedish welfare programme that aims to promote children’s health and an equal start in life. Trust can be used as an analytical tool to determine its significance at different levels – individual, professional, organisational and societal – and the interplay between these levels. We have also shown the role of trust in facilitating collaboration between individuals, groups and or-ganisations. As Gilson (2003) points out, ‘Trust breaks down the bar-riers that prevent or constrain cooperative behaviour’ (p. 1458). The theoretical framework would also be useful to analyse other kinds of welfare programmes characterised by a web of relationships, and con-sequently, useful to shed light on why some programmes are successful, while others are not. Qualitative and quantitative studies on Grow Safely – such as interviews with politicians, civil servants, managers, professionals and participating parents in addition to surveys to parti-cipating parents – will contribute to refine the model.
Author statement
All authors have contributed with ideas, to the design of the paper and to the writing of the paper.
Declaration of Competing Interest
The authors declare that there are no conflict of interest. Acknowledgements
This paper was supported by the Swedish Association of Local Authorities and Regions. We would like to thank professor Per-Anders Tengland, Malmö university for valuable comments on the paper. References
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