In this article we describe and diagnose ailments suffered by the so-called ‘medical insurance decision-making support tool’ that was published in 2007 as part of a major reform of the Swedish social insurance. Through document studies and interviews the guideline is analysed and compared with a reference case, a guideline within cardiology. Particular attention is paid to different types of objectivity and how they relate to the sick-listing guidelines and their uncertain, multi-professional, high-stakes or ‘post-normal’ character. Conflicting concerns and probably unavoidable choices are found in the ambitions, formats, implementation mode and experts of the guidelines.
Promotion of healthy behaviour is increasingly highlighted worldwide as a way to improve public health, prevent disease incidence, and decrease long-term costs for healthcare. In Sweden the National Board of Health and Welfare (NBHW) used the well-established format of national guidelines to facilitate a more widespread use of approaches for promotion of healthy lifestyle habits in healthcare.
Aims and objectives:
The aim of this case study was to explore the tensions between public health knowledge and the tenets of evidence-based medicine (EBM) in the creation of national guidelines on lifestyle habits.
Based on data from interviews with guideline professionals and the collected documents of the national guidelines, we examine how NBHW negotiated the conflicts between public health knowledge and the format of national guidelines. An analytical model based on approaches from the sociology of standardisation is used to explore the ramifications of these negotiations.
In line with findings in the sociology of standardisation, we show how conflicts between public health knowledge and the format of national guidelines result in both having to yield on certain points. This, we claim, results in compromise, but perhaps also compromised notions of validity and causality.
Discussion and conclusion:
This case offers important learning about the general compatibility of public health and currently dominant methods of EBM. Important crossroads are outlined, concerning how validity and causality are configured in public health guidelines and how these require extensive epistemological deliberation.
Although increasingly accepted in some corners of social work, critics have claimed that evidence-based practice (EBP) methodologies run contrary to local care practices and result in an EBP straitjacket and epistemic injustice. These are serious concerns, especially in relation to already marginalised clients.
Aims and objectives:
Against the backdrop of criticism against EBP, this study explores the ramifications of the Swedish state-governed knowledge infrastructure, ‘management-by-knowledge’, for social care practices at two care units for persons with intellectual disabilities.
Data generated from ethnographic observations and interviews were analysed by applying a conceptual framework of epistemic injustice; also analysed were national, regional and local knowledge products within management-by-knowledge related to two daily activity (DA) units at a social care provider in Sweden.
In this particular case of disability care, no obvious risks of epistemic injustice were discovered in key knowledge practices of management-by-knowledge. Central methodologies of national agencies did include perspectives from social workers and clients, as did regional infrastructures. Locally, there were structures in place that focused on creating a dynamic interplay between knowledge coming from various forms of evidence, including social workers’ and clients’ own knowledge and experience.
Discussion and conclusions:
Far from being a straitjacket, in the case studied management-by-knowledge may be understood as offering fluid support. Efforts which aim at improving care for people with disabilities might benefit from organisational support structures that enable dynamic interactions between external knowledge and local practices.