Fear of stigma can stagnate action

I’ve been thinking about stigma.  Recently, I have been told colleagues have been reluctant to take targeted actions.  They have been concerned about creating or reinforcing stigma as a consequence.  I have been pondering the considerations and the possible ways forward, so we can improve on that position and enable, not stifle, positive action. 

It is widely recognised that targeted services have disadvantages as, by definition, they do not reach everyone, and have the potential to create stigma from the belief that services are only for ‘failing families’.  They are not unique as both targeted and universal approaches have risks and advantages to be considered in terms of achieving reach, outcomes and impacts. No one wants to bring shame upon children, young people, families, or communities associated with a particular circumstance, quality, or characteristic.  But we should sensitively consider how services are delivered and the intended or unintended consequences.  The ethical principle of non-maleficence requires us to do no harm. 

The nature of attempting to benefit those eligible requires consideration of how restricting services to ‘the few’ can provide greater benefit to less, and how targeting can make some people unhappy about not being able to benefit from access to services.  Universal strategies aim to benefit more people (everyone), yet they could make people less happy and create ‘general’ benefit because the overall effect of the support could be spread so thinly it is diluted.  It could be possible families who have low-income employment can feel stigma as much as, or indeed more than, families in non-working households.  In all events, access based on stigma cannot be a good thing, even if the eventual outcomes are successful. 

In their placement and delivery, past targeted services such as Sure Start children’s centres worked hard to minimise stigma as an unintended outcome.  Glass (1999)[1] described these approaches in terms of principles and values, those being:

• no single blueprint for effective (early) interventions
• two-generational (involving parents as well as children)
• non-stigmatising (not labelling families as ‘problems’)
• multifaceted (targeting a number of factors)
• persistent (lasting long enough to make a real difference)
• locally driven (based on consultation/involvement of parents and local communities)
• and culturally appropriate and sensitive to the needs of children and parents. 

Such ethical values remain highly relevant for the success of many public services.  In the delivery of which we are often charged with the responsibility of doing our utmost to ensure stigma is not associated with participation, as stigma represents potential harm.  But how could or should we approach things?

• we should not expect services to be delivered in the same ways everywhere
• we must support and encourage people to get involved
• we ought to promote and deliver services as positive and non-stigmatising
• we should look for multifaceted activities and connections with other services to situate the service in the space with others
• services should be persistent through its funding and by adding value via other funding and sustainable strategies – longer term, not shorter term, with the ability flex and adapt
• and delivery needs to be locally driven, based on consultation/involvement of local communities, culturally appropriate and sensitive to their needs.

Many service deliverers are already well-versed and experienced in many of these approaches, including learning lessons from previous delivery.  Sometimes, though, the service users’ reality can be they are made to feel different if service offers are segregated awkwardly.  In putting all of this into practice, there are some more considerations in the form of a checklist:

1. Remember, remind, and reassert the reasons why we have the targeted services in all appropriate plans and activities.
2. Carefully construct marketing and communications messaging to focus upon the benefits and outcomes, fun and enjoyment, and support to access. 
3. Help members of delivery teams who may struggle with reconciling the concepts surrounding targeting and stigma.
4. Support message givers, including partners, by providing material and ‘lines to take’ or ‘key phrases’ to effect better communications, reach and engagement. 
5. Consider methods and approaches that reach eligible communities discreetly and directly, with respect and dignity.
6. Enable service delivery to be seamless, inclusive, and not divisive.  The best services, in my view, are where there is a blend of targeted and universal provision, and you struggle to see the join.

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[1] Glass N (1999) Origins of the Sure Start Local Programmes. Children in Society Vol 13. John Wiley & Sons Ltd.