Name: Anouk Vendelbosch
Student number: S2323508
Master: Public Administration
Track: Public Management and Leadership
Supervisor: Dr. C.J.A. van Eijk
Second reader: Dr. B.J. Carroll
16-07-2019
HOW CAN PROFESSIONALS BE
ENABLED TO ADAPT TO THEIR
NEW CO-PRODUCTION ROLE?
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Content
1. Introduction ...1 1.1 Research introduction ...2 1.2 Thesis structure ...4 2. Theoretical framework ...5 2.1 Co-production ...52.2 The changing role of the professional ...7
2.3 The professional within a co-production...8
2.4 Citizens ...12 2.5 Expectations ...13 3. Methodology ...15 3.1 Case description ...15 3.2 Research design...16 3.3 Research sample ...18
3.4 Data gathering and quality ...20
3.5 Validity, limitations and reliability ...22
4. Results...24
4.1 The emergence of the health dialogue ...24
4.2 The focus groups ...26
4.3 Communication with the citizens...29
4.4 Professionals ...31
4.5 Bottlenecks old style and new style health dialogue ...34
5. Discussion ...37
5.1 Co-production ...37
5.2 Different roles ...39
5.3 Skills, resources and autonomy ...40
5.4 Citizens’ motivations ...41
5.5 New theoretical model ...42
5.6 Limitations and suggestions for further research ...44
6. Conclusion ...46
6.1 The answer to the research question ...46
6.2 Practical interpretation ...47
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1. Introduction
In recent years, users and other members of the community have come to play a bigger role in policymaking and the delivery of services in the public domain (Bovaird, 2007). Previously, the service delivery in the public sector was primarily undertaken by professionals. Nowadays citizens become directly involved. When citizens and professionals work together to deliver services this can be called co-production. According to Van Eijk, Steen and Verschuere (2017, p. 323) the co-production of public services involves citizens and professionals, which both take part in improving the quality of the services produced. Citizens and professionals are defined by Nabatchi, Sancino and Sicilia (2017) as two types of participants who are involved in co-production: state actors and lay actors. State actors are in this case the professionals or the ‘’regular producers’’ and lay actors are the voluntary serving people, or the ‘’citizen producers’’ (Nabatchi et al., p. 767). Examples of co-production are a neighborhood watch (Tuurnas, 2015), a parent council at a primary school or a client council (Van Eijk & Steen, 2016).
Some research about co-production is done, but it is still a relative new subject that needs more attention. Most of the existing literature is about the motivations driving co-production (Alford, 2002; Sharp, 1978; Van Eijk, Steen & Verschuere, 2017). Some of the literature (Bovaird, 2007; Nabatchi et al., 2017; Brandsen & Honingh, 2016) is about what co-production entails and that it is something that goes further than just citizen participation. Another subject that is shown in the co-production literature is the changing role of the professional. Service delivery ‘with’ the citizen instead of public service delivery ‘for’ the citizen (Thomas, 2013), or from ‘public services for the citizens to public services by the citizens’ (Osborne, 2010; Osborne and Strokosch, 2013; Pestoff, 2006, 2012). This is a different way of working from the way the professionals were used to in the previous governance type, Classic Public Administration (CPA). This is a challenge that co-production entails (Tuurnas, 2015). Bovaird and Loeffler (2012) talk about the skills these professionals need in their new role. Quick and Sandfort (2017, p. 214) state that these skills are facilitation skills which are needed to bring the production process together. The new role of the professional in a co-production is also discussed by for example Tuurnas (2015) but in the remaining literature this subject is rather limited.
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It is important to look further into this new role and what it exactly entails. The professional plays a big part in the co-production and therefore it is important to know what he must do and can do different within this new role. It is stated in the literature (Quick & Sandfort, 2017; Vanleene, Voets and Verschuere, 2017) that facilitating skills are important, but what are these facilitating skills exactly? These facilitation skills are needed to bring the co-production process together, so that makes it important to know what these skills exactly are. This is something that remains unclear from the current literature and needs further investigation. Moreover, the culture and the capacity of the organization where the professional is working are also important. The organization needs to facilitate the professional in the co-production process. Likewise, research (Fledderus, Brandsen, & Honingh, 2015) shows that the organizational setting can also hinder or constrain the professional. Therefore, more research towards this new role is needed. In the next section the selected case to do so will be discussed.
1.1 Research introduction
To look further into this subject, this research will focus on the project ‘Gezond en Gelukkig
Den Haag’ (Healthy and Happy The Hague). This is a cooperation between the LUMC (Leiden
University Medical Centre) and Leiden University, campus location The Hague. This project focuses on vulnerable groups in the region of The Hague and strives to make a link between professionals and the citizens of vulnerable neighborhoods. How can these citizens become more involved in (preventive) care and how can initiatives of citizens be more involved? This research will focus on one of the initiatives of this project: ‘De Gezondheidsdialoog’ (the health dialogue).
In recent years, professionals and residents of the neighborhoods Schilderswijk and Rivierenbuurt in The Hague have given shape to this initiative. The reason for this is that the experience of general practitioners within these neighborhoods is that lifestyle advice and programs rarely engage their patients, especially these people with a low level of education and people with a non-Western background (Uitewaal, Atema, & Middelkoop, 2017). It was therefore decided to organize a dialogue between care providers and residents in order to make an inventory of the most important health problems in the neighborhood. Thereafter it was investigated who should play which role in order to tackle these problems successfully. In addition, the aim was to change from 'professional in the lead' to ‘citizen in the lead'.
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This first initiative to organize a dialogue was initiated in 2013 by the Gemeentelijke
Gezondheidsdienst (GGD) Haaglanden (Municipal Health Service). However, this original
initiative did not work out as proposed. The dialogue turned out to be a successful way to surface health problems in the neighborhood. However, what did not work was the part of getting the citizens in the lead to come up with interventions and implement these themselves. Though the original aims turned out to be hard to achieve, still the GGD consider the instrument to be useful. Therefore, they want to organize the dialogue again. But now in a different way and in a different neighborhood (namely Moerwijk). The exact interpretation of this plan is yet developing.
It is interesting to research this case because it is a typical co-production example where citizens become directly involved (Bovaird, 2007). Also, the idea of citizens becoming ‘in the lead’ fits the idea of co-production as among others formulated by Bovaird and Loeffler (2012). Furthermore, Vanleene, Voets and Verschuere (2017, p. 56) state that the presence of professionals in community development is even more important than in public services. The aim of the health dialogue is that the neighborhood ‘as a whole’ develops, so the whole community. Here the professionals must form the important link between the vulnerable citizen and the government. At neighborhood level, these are often community workers who bring citizens together (Tuurnas, 2016), which is the case in this project. This is also consistent with the aforementioned growing demand for professionals to have facilitation skills that are needed to bring a co-production together. So, it is important to know how this professional can be enabled to adapt to their new role within a co-production.
However, it remains unclear exactly how community workers (professionals) fulfill their role (Vanleene, Voets, & Verschuere, 2017). The health dialogue is about being facilitative towards the patients/residents and growing a network around the patient. This offers the possibility to find out what exactly these facilitation skills are and why they are needed. Moreover, it is important to see how the organization, which the professionals are part of, influences this new role, or enables the professional to adapt to their new role. From this the following research question is formulated:
‘’How can the professionals be enabled to adapt to their new co-production role in the project ‘the health dialogue The Hague’?’’
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To perform this study, qualitative research will be carried out. This leads to different insights into what is needed to let this production be successful and what this new co-production role entails. By interviewing different professionals, new perspectives can be linked to the existing theory (Piore, 2006) about what is needed in a co-production. Furthermore, qualitative research looks at how people interpret and experience this in their community world (Ritchie, Lewis, McNaughton Nicholls, & Ormston, 2014). Therefore, in this case the focus is on how professionals experience this initiative and their new co-production role and how this can be optimized. In addition to qualitative research, the depth of the subject more broadly can be investigated and explored (Verschuren & Doorewaard, 2007). The focus here lays at the actor perspective (Hermanowicz, 2002); the subjective meaning given by the professionals about how they can be enabled to adapt to their new role.
1.2 Thesis structure
In chapter two the theoretical framework is presented. First the concept co-production is further explained. Then the changing role of professionals due to co-production is discussed. Next the actual roles a professional can have within a co-production are mentioned, as are the motivations’ citizens have to co-produce. In chapter three the methodology is discussed. First the case, the project ‘Gezond en Gelukkig Den Haag’, is discussed. Next the research design, the research sample, the data gathering, quality, validity, limitations and reliability are discussed. The results are presented in chapter four, based on the answers the respondents gave to the questions in the interviews that were conducted. The researcher's interpretation is substantiated by means of quotations. In chapter five the discussion is viewed, which concludes in a new theoretical model resulting from the research. The limitations and further research suggestions are also given here. Finally, in the conclusion the main question is answered, and the practical interpretations are discussed.
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2. Theoretical framework
The term co-production has been used since the 1970s to give a further explanation of practices that involved citizens in the delivery of public goods (Nabatchi et al., 2017). In order to gain a better understanding of this phenomenon, this chapter discusses in detail the theoretical framework of co-production. Various studies are examined to ensure a good analysis of co-production. The central question focuses on how the professionals can be enabled to adapt to their new co-production role. But what is this ‘new’ co-production role exactly? What does ‘be enabled’ mean? In what kind of ways can the professional be enabled? What are the success factors of a co-production? These are some of the questions that will be addressed in this chapter.
In order to formulate an appropriate answer on these questions, it is important to explore the topic from the perspective of the different stakeholders being involved. First, there is the professional, who has to adapt to this new role. Second, we have the organization where the professional is working for. We will see that the organization has an important role when it comes to enabling the professional and as such impacts on how professionals actually make this change. Last, the citizens who are involved in the co-production take an important role since the professional needs to motivate them to co-produce. Therefore, it is important to explain these three perspectives further in this chapter. First, co-production as a whole will be discussed. Next the changing role of the professionals will be explained after which the new role within the co-production will be discussed as where the organization also plays a role. Then concluding with the citizens within a co-production, with their motivations to co-produce examined.
2.1 Co-production
The literature on production starts with the article from Ostrom (1972) about co-production in metropolitan areas. Brudney and England (1983, p. 59) elaborated on this and defined co-production as ‘’an emerging conception of the service delivery process which envisions direct citizen involvement in the design and delivery of city services with professional service agents”. The New Public Management (NPM) is an explanation of the upcoming involvement of non-governmental actors in public services (Nabatchi et al., 2017, p. 767). In the 1990s, attention decreased about co-production, but in the twenty-first-century
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popularity again arose. Nabatchi et al. state, that despite this popularity, a clear definition of co-production is hard to define. Co-productions can namely entail several activities in traditional but also in untraditional service delivery areas. Moreover, a broad range of actors can be involved. The drawback to this flexibility is the difficulty in correctly labeling what activities are in fact co-production. Notwithstanding this, a broad definition enables the concept to be applied in numerous situations. (Nabatchi et al., 2017, p. 768).
Osborne and Strokosch (2013) name the improvement of the quality of service as an objective of co-production. This improvement can be achieved by for example consultation and participating in planning. They call this participative production. Another form of co-production which they mention is enhanced co-co-production. In enhanced co-co-production the focus is on user-led innovation and ‘’the use of knowledge to transform service delivery’’ (Osborne & Strokosch, 2013, p. 40).
Nabatchi et al. (2017) define four different forms of co-production, linked with the phases of the service cycle. First, there is co-commissioning: the priorities are discussed about what needs to be delivered and to whom and the desired outcomes (Bovaird & Loeffler, 2012). Second, at co-designing the focus is on the experience of the citizen. Third is co-delivery, which is focused on the direct delivery of services. This form centers quality (Osborne & Strokosch, 2013). The last form of co-production they discuss is co-assessment, which focuses on the evaluation of the public services. Bovaird (2007) also states co-production can take place in different forms. For example, a heart attack patient can co-produce with the professional in two ways. On the one hand he can adopt the advice he got from the professional (e.g. diet and exercising), and on the other hand he can communicate this to his community and hereby serve as an ‘expert patient’ (Bovaird, 2007).
Service delivery in the public domain can no longer be seen as a one-way process (Bovaird, 2007). Users of the service and their community play an increasingly significant role in the service delivery process. However, this demands that the professionals must communicate in a different way with these users and their community (Bovaird, 2007, p. 846). Bovaird (2007, p. 847) defines co-production as: ‘’the provision of services through regular, long-term relationships between professionalized service providers (in any sector) and service users or other members of the community, where all parties make substantial resource contributions’’. In this definition we see elements of co-production as described by Osborne and Strokosch (2013). It is a combination of participative and enhanced co-production. Users
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have divergent interests in a co-production (Bovaird, 2007), which has also implications for the professionals. The professional must be able to perform various roles, depending on the co-production (Bovaird, 2007; Osborne & Strokosch, 2013). These roles will be further discussed within section 2.3, but first the changing role of the professional will be described in section 2.2
2.2 The changing role of the professional
The changing role of professionals can be linked to the different types of governance (Brandsen & Honingh, 2013). Osborne (2010) made the distinction between Classic Public Administration (CPA), New Public Management (NPM) and New Public Governance (NPG). The first one focuses on the law, a differentiation between politics and administration and the power of professionals (Lane, 1995). NPM focuses more on output control, whereas NPG can be seen as an archetype of the way public service delivery is grounded in organization and network theory (Osborne, 2010).
Brandsen and Honingh (2013) explain the effect of the changes in governance types on the role of the professional. In CPA the professional community remains dominant, even if there is a professional bureaucracy, and this gives the professional a lot of autonomy. Here, the professional remains a bit ‘magical’ and as such there is a clear division between the professionals and non-professionals (p. 880). Conversely, in NPM the autonomy of the professional is diminished (Green, 2009). It is no longer the individual capacity of the professional which matters, but the overall quality of the service. The difference between professionals and non-professionals has eroded (Brandsen & Honingh, 2013, p. 881). In NPG, the focus for professionals lays at networking, building new social relationships and building new communities. The focus is more on the operational side of organizations which includes for example service outputs and the specification of a product (Brandsen & Honingh, 2013).
Within this new role, where the focus is more on the operational side, the professional needs to change in their behavior and skills. They have to co-produce with more actors and in a different way than before. To look further into these behavior and skills, the subject of professionalism needs more explanation first. The concept professionalism has different interpretations (Brandsen & Honingh, 2013). Professionalism is about content (Noordegraaf, 2007). This means that professionals know their content because they have followed the right education for it. They have the knowledge and can apply this to specific cases (Freidson, 2001;
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Noordegraaf, 2007). Professionals have learned several skills on how to apply this knowledge (Noordegraaf, 2007). Theories about professionalism (Freidson, 2001; Noordegraaf, 2007) focus namely on different aspects of professionalism, for example the content of the work of the professionals in service delivery or the main characteristics of individual professionals (Brandsen & Honingh, 2013, p. 877). This leads to different definitions of the professional, although most of them entail that the professional: 1) has a certain knowledge, 2) belongs to a group of people with the same knowledge, 3) this group is a legitimate community and 4) has autonomy to deal with their own business. To fulfill their practice, professionals have a specific knowledge and expertise (Freidson, 2001). Knowledge can be divided in tacit and scientific knowledge (Brandsen & Honingh, 2013, p. 877). Tacit knowledge is learned ‘on the job’ and scientific knowledge is acquired by obtaining a degree at university.
So, due to the change in types of governance, the role of the professionals has changed. In NPG we see that the focus for the professionals is for example more on building new communities, as is an important focus within a co-production. Four characteristics of the ‘old’ professional are mentioned, which will be revisited in the next section, where the difference of these characteristics is highlighted within a co-production.
2.3 The professional within a co-production
The four aforementioned characteristics of the professional are of course slightly different within a co-production. First, the knowledge difference between the professional and the citizen is getting smaller. Expert knowledge is nowadays no longer only available to a small amount of people, but available for the wider public. Therefore, the work of the professional seems less ‘magic’ than before (Brandsen & Honingh, 2013, p. 877). For example, patients themselves are already looking for information about their illness, outside of the professional. So, patients are getting more involved in the delivery of health care (Brandsen & Honingh, 2016) and therefore the medical knowledge gap between them and doctors has narrowed.
Second, it is possible that the professional belongs to a group of people with the same
knowledge. However, within a co-production, this can be different. The professional still might
belong to the group of people in the same knowledge field, but within the co-production they work together with other disciplines, namely citizens. These citizens might have a different kind of knowledge about the same subject. For example, in the case study of Tuurnas, Stenvall and Rannisto (2016, p. 142), the professionals had skills obtained by education and learned
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through their professional work, whereas the citizens had different backgrounds, life experiences and worldviews about the service.
The third characteristic involves the legitimacy of the professionals. But what happens with the accountability within a co-production, who is responsible? The issue of accountability becomes more important within the changing environment of producing and delivering public services (Bovaird, 2007; Hupe & Hill, 2007; Osborne, 2010). Hupe and Hill (2007) state that within the multi-dimensional governance, the accountability of public services is divided over different actors, on different levels. There are different forms of accountability: public-administrative accountability, professional accountability and participatory accountability (Hupe & Hill, 2007). The latter characteristics highlights the role of the citizen: participatory citizenship. Tuurnas et al. (2016) consider the last form as a mode of co-production (p. 136). Norms and accountability processes are within a co-production not only set by professionals. In their case, Tuurnas et al. (2016, p. 143) even found that participatory citizenship can improve the interaction between the service provider and the client. When the professionals were accountable, so were public-administrative accountability, the citizens might experience a certain amount of distrust because of their role as authorities (Tuurnas et al., 2016).
Last, the professional does have autonomy to deal with its own business, but in co-production he must share this autonomy with the user. As mentioned before, it is not anymore only the professional who has the knowledge and who applies this on the other actor, but now the citizens also apply their knowledge on the professional. Furthermore, the interaction about defining what knowledge is relevant is also important (Brandsen & Honingh, 2016, p. 430). Knowledge creation is an important aspect within a co-production, combining general core knowledge (professional) with situational local (citizen) knowledge. Neshkova and Guo (2012) call this ‘knowledge sharing’. Clarke and Newman (1997) state that professionals became organizational professionals. Freidson (2001) and Tummers (2012) have a similar view on this, they state that the role of the professionals has changed within organizations, from a controlling way to a more supportive way. Professionals in for example public health or teaching were incorporated into organizations in the public sector (Brandsen & Honingh, 2013, p. 878). Because the operational mode of an organization changed to focusing more on output, the professional needed to adapt to this new focus in organizations. This means their orientation needs to shift from the community to the manners of the organization and the preferences of the customers (p. 878).
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Professionals must adapt to this new reality and consider how they can fulfill their new role (Van Eijk & Steen, 2018). Vanleene, Voets and Verschuere (2017) distinguish four different roles of the professional: friends, leaders, mediators and representatives.
1) Friends: have a supporting role. Professionals have a lot of personal contact with the co-producers and in this way try to stimulate the co-producer's own development.
2) Leaders: function as the foreman within the co-production process and try to steer the co-producers in the right direction with directions and instructions. An advantage of this is that it can facilitate the anticipation of citizens, but a negative effect can be that citizens have little room for real development and can hardly make an active contribution.
3) Mediators: aim to ensure that cooperation runs as smoothly as possible and try to bring the various actors together. Also creates dialogue to join different perspectives.
4) Representatives: ensure that the interests and wishes of the co-producers are visible within the public organization. Often this means that the professional does not so much make an active contribution to the collaborative project itself but focuses primarily on contacts with financiers or managers at a higher hierarchical level (Vanleene, Voets, & Verschuere, 2017) .
These four roles show us that the professional brings the citizens and communities together, and therefore gets, within the coproduction process, a more connecting function (Van Eijk & Steen, 2018, p. 122).
Generating connectivity means that the professional needs different skills to fulfill this new role (Van Eijk & Steen, 2018). According to Vanleene, Voets and Vershuere (2019, p. 3), the classic leadership characteristics such as control and power are replaced with previously undervalued skills. Skills that are needed now are open-mindedness, being able to listen and to perform within a group (Vanleene, Voets, & Verschuere, 2019). ‘Voice’ is hereby also important. Citizens do not only need to feel they can speak but also must feel heard and understood (Buckwalter, 2014; Fledderus, Brandsen & Honingh, 2015). The professional plays an important role here. He or she can make sure the citizens feel empowered and that fairness can be achieved in a co-production. Furthermore, to create knowledge together with the citizens, mutual learning and trust are important factors (Kim, 2010). Both the citizen and the
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professional can learn in a co-production. As mentioned earlier, citizens can have the situational or local knowledge and can therefore propose innovative solutions. Vanleene, Voets and Verschuere (2019, p. 11) conclude in their article that this so called ‘street-level’ professional needs the right skillset, but also enough time, resources and autonomy to fulfill their new role correctly.
Tuurnas (2015) did a case study in Finland about a pilot neighborhood project to report on how professionals can perform within a co-production. This project was initiated and designed by the professionals and aiming for service innovation through co-production (p. 587). She states that the role of learning is important in a co-production. The professionals have to learn what they must do differently in this ‘new role’, now they do not know this exactly (p. 591). Furthermore, the aim of the co-production must be clear, either to foster participatory democracy, or to transform the service. Otherwise this will create confusion for the professionals about the co-production. Another important finding is that the amount of introversion of the professional can be a negatively influencing factor on the co-production. ‘’Opening up’’ is essential according to Tuurnas (2015, p. 592) to avoid path dependency. This means creating meaningful platforms which increase effective interaction.
So, some things are stated in the literature about this new role of the professional. In this new role it is for example more about knowledge sharing, rather than the professional who has all the knowledge. In this case, we look at how the four characteristics of professionalism are reflected in practice. This is the deductive part of the research. It is expected that these four characteristics will resurface in the co-production project under scrutiny. What also can be tested for, is whether the four mentioned roles a professional has (Vanleene et al., 2017), all come back in this co-production, or maybe just a few. The skills part is likely to be more inductive since it is presently unclear what this new ‘facilitating role’ exactly means. How can the professionals facilitate the citizens within the co-production? How does the connecting role come to the fore in practice? These are things that needs further attention within this research.
To facilitate the citizens, it is important to know who these citizens are and what their possible motivations are to join the co-production. This is discussed further within the next section.
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2.4 Citizens
Working with the public can take place in different forms (Thomas, 2013). Citizens can work as partners with the government, or as advisors on questions about what services to provide. However, most of the time, the professional has to deal with different roles of citizens at the same time. This causes a dual challenge for professionals (Thomas, 2013, p. 786). On the one hand they need to know what these citizens want, in their role as a citizen, customer or partner. On the other hand, they need to know how to interact with these citizens in the different roles. Citizens are the lay actors, and voluntarily involved in the co-production (Nabatchi et al., 2017). They can act on the individual, group or organizational level. Part of the new role of the professional is that he or she motivates the citizens within the co-production. Therefore, it is interesting to look at the motivations of citizens to co-produce. Quite some attention is given in the literature to the motivations of citizens to co-produce; sometimes also referred to as drivers or incentives (cf. Sharp, 1978; Clary, Snyder & Stukas, 1996; Alford, 2002; 2009; Loeffler & Bovaird, 2016; Van Eijk & Steen, 2016).
Clark and Wilson (1961) divided motivations into three kind of motivations: material, solidary (intangible) and purposive. Thomas (2013) also mentions material motivations, but he says that you should not only use these but use them in combination with other motivations. Only using material motivations will not make the co-production to a success (Alford, 2009). Alford (2002) names also intrinsic rewards as a motivation to co-produce. Van Eijk and Steen (2016, p. 42) describe three sets of factors that influence the individuals’ willingness to co-produce: (1) perceptions of the co-production task and competency to contribute to the public service delivery process, (2) individual characteristics in terms of socioeconomic profile and social connectedness, and (3) self-interested and community focused motivations. Within the first factor different concepts are important. Van Eijk and Steen mention salience, as does Pestoff (2002) as an influencing factor in the decision-making process for citizens to co-produce. Salience has to do with if the citizen finds the topic of the co-production important enough to invest in this (Van Eijk & Steen, 2016, p. 30). Other factors are internal and external efficacy. Internal efficacy means the personal competence of the citizen to participate effectively in the co-production (p. 31). External efficacy has to do with the professionals, and if he creates room for communication between them about decision-making processes and service provision. The second factor has to do with the environment
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the citizen is part of (e.g. the community). The third factor is about material rewards and avoiding sanctions as self-interested motivations.
So, within a co-production both the professional and the citizen play an important role to make the co-production successful. Citizens have different motivations to co-produce, like salience and internal and external efficacy. It is interesting to investigate which motivations the citizens have according to the professionals and how the professionals can further develop these motivations. How this is researched is discussed in chapter 3, but first the expectations that have resulted from the theoretical framework are shown in section 2.5.
2.5 Expectations
Based on the above stated literature several expectations are formulated to give a clear overview of what is going to be researched. First, we saw the four characteristics of a professional and how they are different within a co-production. Concluding from the theory I expect the following to notice in the case under scrutiny.
1) The knowledge difference between the professional and the citizen is smaller.
2) The professional does belong to a group of people with the same knowledge, but also works together with other disciplines.
3) The accountability is divided over different actors, on different levels and hereby the form participatory accountability is used.
4) The professional shares his autonomy with the citizens
5) New knowledge is created by combining general core knowledge with situational knowledge.
Second the four different roles of the professional were described and the associated skills. Concluding from this the following is expected:
6) The four roles (friends, leaders, mediators and representatives) are visible within the co-production.
7) The leadership characteristics control and power are replaced with open-mindedness, being able to listen and mutual learning.
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However, how exactly this role should be filled remains unclear. The term ‘facilitating role’ is mentioned, but what is meant by this is vague. This is the gap in the literature that needs further explanation. This is going to be the inductive part of the research, to give a better interpretation to this concept.
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3. Methodology
In order to answer the research question that is set out in chapter one, it is important to make the right choice about which research method is most suitable. The purpose of this research is to gain insights in the health dialogue which is part of the project ‘Gezond en Gelukkig Den
Haag’. Such insights are necessary for practical and theoretical reasons. The first time the
health dialogue was implemented in the co-production setting it did not commence properly. The stakeholders involved have some thoughts about why this did not happen as planned, which are included now in the revised version of the health dialogue the GGD wants to implement in Moerwijk. More insight into how they can perform the health dialogue better when attempting to restart the project is critical to its success. Moreover, this study will advance the relatively limited literature which exists about co-production. As follows from the theoretical framework, this research is partly deductive and partly inductive, as will be described in more detail in section 3.2. First, the case will be described. Next the design of the research will be discussed, after which the research sample and the method of data gathering will be discussed. Finally, the extent to which the quality of this research is guaranteed is explained.
3.1 Case description
The health dialogue was initiated in 2013 in the Schilderswijk in The Hague. The idea came from one of the general practitioners at the Schilderswijk, who is also working at the GGD. He gathered some important organizations and people together to discuss this further. Among these organizations were the GGD Haaglanden, welfare organizations Xtra and Zebra,
Regionale Ondersteuningsstructuur Lijn 1, and health center the Rubenshoek. GGD Haaglanden is the health service for all nine municipalities in the Haaglanden region. The GGD
monitors, protects and promotes the health of the population (GGD Haaglanden, 2019). Together, they formed a steering group in which they discussed how they wanted to shape the health dialogue. The main goal they formulated was that through contact between care providers and citizens within the health dialogue, a joint picture could be created of what the problems were in the neighborhood and how they could be addressed, and in the process make the citizens responsible for solving these problems. At this stage in the project only professionals were involved and no citizens, as such it was not a co-production yet.
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After several meetings the opbouwwerkers were instructed by the steering group to approach the citizens to join different focus groups to talk about ‘health in the neighborhood’. Several focus groups were held at the Schilderswijk with citizens from the neighborhood. As a result of these focus groups, the following major health problems were indicated: 1) stress, 2) nutrition and 3) exercise (Uitewaal, Atema, & Middelkoop, 2017). This is the result of the first steps of the co-production. The next step was to empower the citizens to take responsibility to solve these problems. In these follow-up meetings the care workers and the citizens talked about possible solutions to their problems, which should lead to getting citizens ‘in the lead’. However, this turned out to be much harder to achieve than imagined in advance. It was perhaps a somewhat too ambitious goal. This is something that also comes back in the result part (chapter 4). The ‘by and for citizens’ approach did not work out as planned.
The GGD would like to get this initiative off the ground again and planned to implement the dialogue in a ‘new style’ in Moerwijk. In this new dialogue they want to focus more on facilitating the citizen in solving the problems in the neighborhood. Their assessment was that having citizens exclusively in the lead was very difficult to achieve. Why was this difficult to achieve and what was the role of the professional? These sorts of questions are answered in this research. In the next section the further design of this research will be explained.
3.2 Research design
The design of this research is both inductive and deductive. As seen in the theoretical section, parts of this research are described already in earlier theory, but some information is not available yet, not properly conceptualized or not being researched yet. Therefore, a combination of inductive and deductive research is needed (Toshkov, 2016). Inductive research means explaining outcomes based on initial theories and ideas from empirical patterns, while deductive research is more focused on really testing theory (p. 29). Inductive research is used in this study to investigate these ideas that are currently only mentioned in general terms in the literature, but of which the exact meaning is not clear. As such, the ideas are too abstract and general to formulate concrete hypotheses. Instead, it is valuable to study these ideas more in depth to add a concrete understanding. Since some parts of this research are described in the theory, a small part of this research will be deductive. With deductive research some parts of the theory one expects to see in practice as well, are tested. For
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example, the different roles of a professional within a co-production, as described in section 2.3. Expected is to see the role of the leader back in practice, since every project mostly has a leader-person. Therefore, this is tested. A combination of inductive and deductive research fits best within this research.
The data is conducted by doing semi-structured interviews. Semi-structured interviews include some questions which give guidance to the interview, but also leave enough space for follow-up questions or topics the interviewee thinks are important to discuss as well. To the design the interview, different topics where chosen, which derived from the theoretical framework. Then interview questions were prepared per topic. The following topics were used: general information, co-production, professionals and reflection. The interview starts with retrieving some general information from the respondent, like age, background, education. The topic co-production derives logically from the theoretical framework, since it is mostly about co-production. Questions relating to who was involved in the co-production and what is the goal of the co-production are included in this topic. Furthermore, the topic of professionals is important to answer the research question. Here the focus lays on the role of the professional, how this role has (probably) changed and what kind of skills they need to make the co-production successful. The last topic, reflection, is chosen to just wrap-up the interview a little bit and where appropriate ask some follow-up questions on earlier answers and to ask about general thoughts about how the co-production can be organized next time. These concepts provide general insight and a work direction (Bowen, 2006). These concepts have also been used as topics to shape the interviews. A topic is a subject or theme that the researcher wants to talk about during the interview with the research participant (Ritchie et al., 2014). In this way a certain direction can be given to the interview, but if necessary, it can also be deviated from where this appears to be interesting (Piore, 2006). After analyzing the interviews, you can choose to add or remove topics. As mentioned, the interview questions were formulated per topic. The type of questions that are formulated here depends on the purpose of the research. This is an exploratory study (Toshkov, 2016) in which an open approach makes sense, so that the participants feel invited to tell their story. The topic list with accompanying interview questions (in Dutch) can be found in appendix I and II. There are two sets of questions, one for the persons who were involved in the health dialogue at the Schilderswijk and one for the professionals who might be involved in the health dialogue at Moerwijk.
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3.3 Research sample
For this research, professionals with different roles within the health dialogue were interviewed. Since this research is about the new role of the professionals, it is important to see what kind of role they performed within the project and what their ideas were about this new role. These professionals were approached via the snowballing technique (Bleich & Pekkanen, 2013). Via Leiden University a contact person of the project ‘Gezond en Gelukkig
Den Haag’ was contacted. This person was in contact with the GGD and the first respondents
were arranged through the GGD. Via these respondents, more respondents were found. This way, important actors were more likely to take part in the research, because they were reached by referral. When the original interviewee was a good source, then the person this interviewee refers to is most likely also a good source (Bleich & Pekkanen, 2013, p. 87). However, it is possible that this technique introduces bias. The referred contacts probably have the same view as the original source (Bleich & Pekkanen, 2013). This way the research can be manipulated. This problem can be mitigated by the researcher by selecting initial interviewees with different backgrounds and being aware of the possibility of bias.
Using the snowball technique, ten interviews were conducted. In table 1 the respondents can be found, anonymized by name. Each interview lasted approximately 45 to 75 minutes. One interview is excluded from the data because this interview contained no useful information. The concerned respondent did unfortunately not have the required information to answer the interview questions. This respondent referred to two other possible respondents who would have the information needed. However, according to Bleich and Pekkanen (2013) the possible problem of bias also works the other way around. These referrals most likely also do not possess the correct information. Therefore, these persons were ‘checked’ with the original source. It turned out these referrals were only shortly involved in the project and would probably not have the information needed. The referrals where therefore excluded from the research. Communication is an essential tool here. Since this was one of the first interviews, this experience was a learning moment for the researcher and was included in the search for new respondents. Some adaption in communication towards the respondents was made in the sense of formulating things clearer.
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Before the first interview was conducted, one exploratory conversation was conducted with respondents D and F. This conversation took about one and a half hour and was about the health dialogue at the Schilderswijk and the new plans for Moerwijk. During this meeting, the experience was that they both had a different expertise and ideas. Therefore, the choice was made to plan two more in-depth interviews with both apart from each other to gain more specific information. Furthermore, one observation was done in the context of this research. Respondent A talked in the interview about a meeting within her project about health in a yet-existing group of women. She offered the opportunity to observe this meeting. This opportunity was taken and here the contact was made with respondent H, she was the conversation leader of this dialogue about health.
Table 1: Respondents information
Respondent Sex Function Role Interview date
A F Health broker
(Gezondheidsmakelaar) at the GGD, area Escamp
Involved in ‘Wijzer in de Wijk’ in Moerwijk
April 18, 2019, 09:00h at the GGD
B F Program leader product development, innovation and digitization at Xtra
Involved in the health dialogue Schilderswijk April 18, 2019, 11:30h at Xtra C F General practitioner at Moerwijk Health Ambassador at Moerwijk May 3, 2019, 13:30h at her general practice
D F Senior epidemiological investigator at the GGD
Involved in setting up the new dialogue
May 7, 2019, 09:00h at the GGD E M Retired, previously employed at the GGD Involved in health dialogue Schilderswijk May 10, 2019, 14:00h at the GGD
F M General practitioner at the Schilderswijk and senior epidemiological
investigator at the GGD
Involved in health dialogue Schilderswijk and in setting up the new dialogue
May 16, 2019, 09:30h at the GGD
G F Opbouwwerker (part of
welfare work in different neighbourhoods) Was ‘opbouwwerker’ at the Schilderswijk May 29, 2019, 12:00h at community center De Kronkel H F Projectmanager at Zorgbelang Inclusief External party, experienced in leading health dialogues June 11, 2019 10:00h at Rotterdam Central Station I F PhD-student (Health Psychologist) at NKI (Dutch Cancer Institute)
Action-researcher, guiding the different focus groups
June 11, 2019, 19:00h via phone at home
J M Opbouwwerker at Moerwijk Was opbouwwerker at the Schilderswijk June 21, 2019, 10:00 h at the community center Moerwijk
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Within the ten interviews, only professionals were interviewed and no citizens. The original idea was to interview citizens too, to get a good combination of professionals and citizens within the case. Professionals could for example think they can make citizens participate in the co-production by using this and this tool, while the citizens may think differently about this. By interviewing both, this could be balanced against each other. Unfortunately, during the research, it turned out to be not possible to interview citizens. Plan A was to talk with the citizens who were involved in the health dialogue at the Schilderswijk, to see what their opinions were and if these are different from the professionals’ opinions. But since the health dialogue took place six years ago (2013), it was hard to reach the citizens who were involved. Plan B was to approach citizens from Moerwijk, to see if they were interested in the idea of the health dialogue and what their thoughts were about the new role of the professional. Respondent C was asked if she could possibly mean something in approaching patients within her practice. She stated that this was not really an option unless it could be guaranteed that this project would be continued following the completion of this research. Her patients were getting tired of the people who came to them to study something, or to gain some information and then left without providing follow-up on the research. Unfortunately, it could not be guaranteed this project would be continued, so reaching the citizens from Moerwijk was not feasible and contrary to their best interests.
3.4 Data gathering and quality
It is important to collect correct, honest data. To achieve this, I used several interview techniques (Bleich & Pekkanen, 2013). First, I gained the trust of the interviewee by introducing myself and mention I study at Leiden University. Hopefully this will remind them of their own days at university and collecting data and encourage them to answer my questions fully and frankly. Furthermore, I explained how the data is going to be used, where the results will be disseminated, and that the information will be attributed anonymous. Hermanowicz (2002) states that it is important in interviews that the respondents remain anonymous. Therefore, this is guaranteed and mentioned beforehand to the interviewees, so they could speak more freely. During the interview, it is important to let go of silences (Hermanowicz, 2002; Bleich & Pekkanen, 2013), a respondent can also drop a silence because
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he is finished talking, but also because he or she is still thinking about an answer. By being able to respond well to this, more information can be retrieved from the respondent. By going into detail using interviews, the underlying ideas / thoughts / experiences can be retrieved. Going into detail during an interview can be done by applying probing, where you follow up on certain questions which require further notice and seem interesting to the researcher (Hermanowicz, 2002).
Furthermore, most of the interviews took place at the GGD in a meeting room. These were private rooms so the interviewees could talk out loud without others to overhear it. All interviews were in private and in a safe environment that was pleasant for the respondent. For example, another interview took place at the general practitioners’ own practice. This way the interviewees would feel at ease during the interview. To guarantee the quality of the interviews conducted, these were recorded with accordance of the interviewees, using a telephone. By recording interviews, matters such as intonation, nuance and giving meaning to words are not lost (Hermanowicz, 2002; Bleich & Pekkanen, 2013). However, since the interviews were fully transcribed afterwards, without taking these intonations and nuances into account, they got lost anyway. Next to recording the interviews it is always important to make notes during the interview (Bleich & Pekkanen, 2013). By making notes you can write interesting key words down which you want to come back on later, but in that moment, you are not able to do it because you do not want to interrupt the interviewee. Also, when the technique does not work as planned, your notes can be used as reference work. One time it did happen that the recording was not saved, due to technical issues, but by using the notes a good sketch of the interview was made.
After transcribing the interviews these were inserted into the program Atlas.ti. In this program, several codes were assigned to different parts of the interviews. For example, a sentence in an interview which mentioned something about the skills a professional need to make the co-production successful is linked to the code ‘skills’. This leads to having lots of codes linked to different parts of the interviews. These codes were then labeled under two ‘family-codes’. These family-codes are the more general codes, under which the other codes were classified. This leads to a coding scheme, which is pictured in table 2. After coding all the interviews, one can filter on a specific code and get all the phrases about this subject in one overview. This is useful for writing the result section and analyzing the interview per topic.
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Table 2: coding scheme
Co-production Professional
Emergence health dialogue Community workers Approaching citizens General practitioners Citizens in the lead Initiators
Steering group Action researcher
Goal New role
Focus group conversation Skills
Motivations Leading focus group conversations Urgency subject Development
Stress Establishing a connection Communication Budget
Bottom-up Autonomy
Trust Time
3.5 Validity, limitations and reliability
Toshkov (2016, p. 117) states that measurements within a research should always represent in a valid way the underlying variables and theoretical concepts. Internal and external validity are both important for having an appropriate research. Internal validity is obtained by conducting ten in-depth interviews. This is a good amount to get some in-depth information about a specific case. This ‘new’ theory can be applied to new cases. However, it is crucial to realize that it is just a conjecture that needs further probing to determine its validity and relevance (Toshkov, 2016, p. 39). This can be done by matching this generated explanatory theory against new data about the same or new cases. External validity is about generalizability of the study within other fields. However, a limitation of doing a single-case study is the dubious possibility of generalization (Toshkov, 2016, p. 304). There is only one case under investigation and this case is chosen because of its substantive importance rather than its methodological importance. External validity is in this way not ensured, unless one assumes ‘’absolute homogeneity of the population of cases and deterministic causal links’’ (Toshkov, 2016, p. 304). However, generalization is not the goal of this research and therefore this is not a deal-breaker.
The goal of this research is to fill the aforementioned ‘gap’ about co-production in the literature and scholarly debate. There is no explanatory research yet for this case, so
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generating research is appropriate here. To help to generate theoretical ideas, an in-depth case study can be used (Toshkov, 2016, p. 38), as is done in this case. Furthermore, single case studies can lead indirectly to generalization (Toshkov, 2016, p. 305). This single case study is embedded in a larger theoretical body of literature and aims for extending the current literature and uncover maybe new mechanisms. Therefore, the study does provide general arguments that might be useful to explain other cases. However, to provide these general arguments, the study must rely on the existing theory. Since some of these building blocks are missing in the current theory, it is hard to connect the within-case analysis material to this theory (p. 305). Due to this, there might be no compelling explanations, but it would lead to new insights into the gap there is now in the theory.
When gaining these new insights, it is important to make sure the measures within the research are reliable. Somebody else should, by applying the same measurement, get the same insights or at least similar as you (Toshkov, 2016, p. 117). It is very rare though to achieve perfect reliability. Especially within the social sciences, where there is the case of elusiveness of the phenomenon of interest (p. 117). When doing interviews, it is hard to achieve complete reliability. The same questions can be asked, but the respondents can answer in a different way or say something different because they made up their mind. However, reliability can be guaranteed by asking the interview questions as open as possible and thereby avoiding the observer error. Observer error means that the researcher asks the interview questions in such a way, he or she biases the answers to these questions (Saunders & Lewis, 2012). It is important to give no indication towards an answer. Reliability within qualitative social sciences research can be achieved, but this is difficult.
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4. Results
The empirical data is analyzed in this chapter. As discussed in the method chapter, interviews of an average of one hour were conducted among ten respondents, which consist of several professionals in the ‘health’ field. Most of them were involved in the health dialogue at the Schilderswijk and some are connected to Moerwijk. Taking confidentiality into account, the respondents are numbered as Respondent A to J. The results are presented per topic and will be substantiated on the basis of quotes from the respondents. First the emergence of the health dialogue is explained. Next the focus groups are discussed, as is the communication with the citizens. Then the different roles and skills perceived by the professionals are discussed. Last the bottlenecks within the health dialogue are mentioned.
4.1 The emergence of the health dialogue
As mentioned in the case description, the health dialogue was initiated in 2013 by different parties. The original idea of the health dialogue came from respondent F. As a general practitioner at the Schilderswijk he noticed that sometimes all patients were telling the same story and he gave the same advice ten times a day. This is not efficient and, moreover, these are general advices that everybody knows. Take for example smoking, people know that this is a bad habit and they need to quit smoking, but they do not quit it. Maybe the citizens experience stress and they believe that smoking reduces the stress, or maybe there are other factors which influence this. This is shown in the following quote, stated by one of the community workers.
‘The idea came from the GPs, who had the idea that the advice they gave to residents / patients didn't really work and many people came with the same symptoms.’ (Respondent G)
Respondent F thought it would be more efficient to translate these problems into more general neighborhood problems, a problem for all the residents. This way the residents would probably act sooner, because these problems are their own problems and the ones from their followers.
Another reason why the health dialogue could be a good idea was that several initiatives around health were organized, but then only five people showed up to these
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meetings. These were the people who came to every event and were not the people you want to reach. The people who are coming to these kinds of events are already active and problem-solving oriented. However, you also want to reach the people who are for example lonely, to see what their ideas are, but since they are isolated, they probably do not look for those events. Respondent H reflects on this with the following quote:
‘That is the most difficult thing, that is exactly what I sometimes struggle with. What I am trying to do is get in contact with them through professionals. Very occasionally you get to speak to someone who is really alone.’ (Respondent H)
So, to also solve this problem, the idea was that if the citizens themselves were in the lead and get more responsibility, they could attract other citizens much more easily. This would result in getting a whole different group of people, larger and with more interesting people. These meetings could continue and did not have to stop after one or two meetings. To do so, you will need the citizens’ efforts; the professionals alone cannot arrange this. The ideal way was that the citizens did the organizing part and the professionals the supporting part. The following quote underlines which two things emerged into the health dialogue.
‘On the one hand as a general practitioner moving things to the neighborhood because I kept telling the same story and on the other hand problems among a larger group of citizens, these had to live in the neighborhood. If you add those two things together, this results into the health dialogue.’ (Respondent F)
Respondent F shared his thoughts with several people from his network at the Schilderswijk and the GGD. This resulted in the steering group around the health dialogue. They sat together in several meetings to discuss about what would be effective to make people think about their lifestyle so that the same problems no longer end up with the general practitioners. Involving parties were different care organizations (for example Welzijn), Stion and the GGD. Together they created the idea of the health dialogue. Later, some social workers joined, as well as
opbouwwerkers. An opbouwwerker is somebody who makes the connection between citizens
within the neighborhood, a person who is focused on all the humans in the neighborhood (the closest translation of oppbouwwerker is community worker). The opbouwwerkers were
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switched on to approach the citizens in the neighborhood and recruit them for different focus groups the health dialogue started with. To approach the citizens these three opbouwwerkers used the network they already had within the neighborhood, which consisted of different groups and different community centers. Two of these opbouwwerkers were interviewed and one of them states the following about reaching out to the citizens for the health dialogue:
That is typical community work. Opbouwwerkers know which organizations, associations and groups are in the neighborhood. So, you are going to approach those organizations. (Respondent J)
All together they were responsible for achieving the predefined goal. All the respondents named lots of things when was asked for the main goal of the health dialogue. Some named only making an inventory of the different problems in the neighborhood as a goal, others named getting citizens in ‘the lead’ (Respondent F). The goal mentioned by Respondent E covers most of the goals that were mentioned and, in my opinion, gives the best impression of the goal.
‘The aim of the health dialogue was actually to devise interventions that are borne by the citizens themselves. And ideally to even have a role for the citizens themselves. That is very ambitious.’ (Respondent E)
Respondent E describes the goal very clear and mentions a point of critique. The goal was a bit ambitious and therefore maybe not entirely well thought out, which will be explained further at section 4.5. However, the health dialogue did not start with immediately thinking about interventions. They first wanted to collect the different actual problems in the Schilderswijk by organizing different focus groups, which the next section will elaborate on in more detail.
4.2 The focus groups
Once the opbouwwerkers had collected a sufficient number of citizens for the focus groups, these citizens were officially invited via e-mail. They collected around 45 citizens in total who were split into three different groups. To make sure they would really come to the meeting(s),
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these citizens were called in the week of the appointment and texted on the day itself. According to the opbouwwerkers they had to put in a lot of effort to motivate the citizens to join the health dialogue. The next quote gives an illustration of this.
‘We really had to call, e-mail and visit them every day. It was important to say that it is only going to take two hours and then it is done. The location had to be close to the citizens. And you need a little bit of luck. But also address citizens on their personal title and say well, I assume that you are coming, we think your opinion is important.’ (Respondent J)
So, the opbouwwerkers have really contributed to the fact that the citizens were motivated to participate in the health dialogue. According to the other respondents, intrinsic motivation played a role here as well as extrinsic motivation. Most respondents think the intrinsic motivation of the citizens lay in the fact that they found it important to talk about (their) health. However, one respondent states that health is maybe not as important to most of the citizens, since they have other problems that are more important on that moment.
‘I think the subject was the biggest problem. Health, and urgency. That is not at the top of the list.’ (Respondent B)
Many citizens are in debt restructuring and therefore do not have health at their top priority. Another respondent, a general practitioner at Moerwijk, mentions mold in homes as a big problem in Moerwijk, which the next quote illustrates.
‘There is a lot of stress here in Moerwijk, either due to debts, or due to mold in their homes. That needs to be solved, according to the Maslow pyramid, before you start focusing on health.’ (Respondent C)
Some other respondents confirm this statement. However, one respondent states that if you broaden the subject, also things like stress due to debts fall under the subject of health. Stress, due to whatever reason, health related or not, can eventually also influence your health. She states that if you give the citizens enough attention and ask the right questions, they are more than willing to talk about their problems and share their ideas.
28 ‘How can you let people participate? If you really pay attention and are really interested, then I think it will work. I think it's important to have the right intentions. I'm convinced of that.’ (Respondent H)
The extrinsic motivation was caused by the fact that the citizens got gift cards for participating in the health dialogue. Some respondents say the citizens got these gift cards after participating in three meetings and they did not know about this up front. Others state this was arguable, and it was sometimes used as a lure.
To organize the focus groups, a researcher from the LUMC was appointed (Respondent I). She gave some frameworks on how the focus groups had to be designed and what were the subjects people could talk about. In these focus groups the same three themes emerged in all focus groups; nutrition, exercise and stress, whereas stress was far at the top. Several things were categorized under stress: financial stress, worries about money/hard debts and everything that you can classify as psychosocial stress. This can vary from problems of upbringing to unemployment to the feeling of being discriminated against and the poor image of the Schilderswijk. The importance of stress is illustrated below by respondent E.
‘As long as nothing happens, you can forget about it in the areas of nutrition and exercise. Stress is really at the top and blocks the other two as well.’ (Respondent E)
How far stress was at the top is also apparent from one of the first meetings that was organized. This was not yet a focus group, but more a general meeting to talk about health and the three themes: stress, nutrition and exercise. About ninety people came to this meeting and they had to take place at the subject they wanted to talk about. This turned out a little bit different then they had thought beforehand.
‘Well a complete allergy broke out. Three people went to diet, two people to exercise and the other 85 to stress. There was one social worker to lead that conversation and a whole room was calling what was a source of stress for them.’ (Respondent F)
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They were not prepared for so many citizens. They thought each opbouwwerker could lead about a ten to fifteen citizens. The following meetings were more organized. In the next section the communication with the citizens within the focus groups will be discussed more detailed.
4.3 Communication with the citizens
Besides the fact the opbouwwerkers were called in to approach the citizens for the focus groups, they were also the ones who had to lead these focus group conversations. Before doing so, they followed a training on how to lead such conversations. This training was organized by respondent I, who had because of her background in (academic) research the required knowledge and skills to do so. According to her, a couple of things were important when communicating with the citizens during the focus group conversations.
‘You must have faith that the information will come, have a wait-and-see attitude, but also be able to level well, so do not throw in jargon.’ (Respondent I)
She practiced with the opbouwwerker on the conversation techniques. The opbouwwerkers were in terms of accessibility the right persons to lead the focus group conversations. However, they needed the training to learn how to lead such a conversation. Within a group there are certain group dynamics: one or two people take the lead and the rest just sits there and says nothing. Attention was paid to this within the training, how can you deal with this, how can you involve the rest as well? Furthermore, within this target audience, the Dutch language was not as well spoken by all the attendees. They were selected on the fact that they could speak well enough Dutch to participate in the meeting. However, these target audience might be used to others taking the lead, so they need probably longer to fill up silences. This was a challenge for the opbouwwerkers, because your natural inclination is to fill up the silence. It was hard for them to just let the silences be. The following quote of the researcher who attended all the focus groups, visualizes this.
‘What I found amusing to see is that the social worker generally found it difficult to drop silences. In the end we managed to get a bit freer of certain natural tendencies that belong to the moment to be able to follow a bottom-up approach.’ (Respondent I)
