Social Science & Medicine 104 (2014) 80e87

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Social Science & Medicine journal homepage: www.elsevier.com/locate/socscimed

Rewarding altruism: Addressing the issue of payments for volunteers in public health initiatives Jane South a, *, Martin E. Purcell b,1, Peter Branney c, Mark Gamsu a, Judy White a a

Institute for Health & Wellbeing, Leeds Metropolitan University, UK Policy Research Institute, Leeds Metropolitan University, UK c School of Social, Psychological and Communication Sciences, Leeds Metropolitan University, UK b

a r t i c l e i n f o

a b s t r a c t

Article history: Available online 16 December 2013

Lay involvement in public health programmes occurs through formalised lay health worker (LHW) and other volunteer roles. Whether such participation should be supported, or indeed rewarded, by payment is a critical question. With reference to policy in England, UK, this paper argues how framing citizen involvement in health only as time freely given does not account for the complexities of practice, nor intrinsic motivations. The paper reports results on payment drawn from a study of approaches to support lay people in public health roles, conducted in England, 2007e9. The first phase of the study comprised a scoping review of 224 publications, three public hearings and a register of projects. Findings revealed the diversity of approaches to payment, but also the contested nature of the topic. The second phase investigated programme support matters in five case studies of public health projects, which were selected primarily to reflect role types. All five projects involved volunteers, with two utilising forms of payment to support engagement. Interviews were conducted with a sample of project staff, LHWs (paid and unpaid), external partners and service users. Drawing on both lay and professional perspectives, the paper explores how payment relates to social context as well as various motivations for giving, receiving or declining financial support. The findings show that personal costs are not always absorbed, and that there is a potential conflict between financial support, whether sessional payment or expenses, and welfare benefits. In identifying some of the advantages and disadvantages of payment, the paper highlights the complexity of an issue often addressed only superficially. It concludes that, in order to support citizen involvement, fairness and value should be considered alongside pragmatic matters of programme management; however policy conflicts need to be resolved to ensure that employment and welfare rights are maintained. Ó 2013 Elsevier Ltd. All rights reserved.

Keywords: Lay health workers Volunteering Payment Expenses Health inequalities Qualitative research Public policy United Kingdom

Introduction To meet the challenge of persistent health inequalities, Morgan and Ziglio (2007) argue that a shift is required towards asset-based approaches that seek to harness the knowledge, skills and resources within communities. Across the globe, there is a tradition of public health programmes where ‘community’ or ‘lay’ health workers deliver healthcare and prevention to underserved communities (World Health Organization, 2007). Lay involvement in health can also occur through volunteering in public services or community-based activities, where volunteer contributions may be

* Corresponding author. Institute for Health and Wellbeing, Leeds Metropolitan University, Queen Square House, Leeds LS2 8NU, UK. Fax: þ44 1138121916. E-mail address: [email protected] (J. South). 1 Current address: Faculty of Education, Manchester Metropolitan University, UK. 0277-9536/$ e see front matter Ó 2013 Elsevier Ltd. All rights reserved. http://dx.doi.org/10.1016/j.socscimed.2013.11.058

classified as regular, occasional or episodic (Low, Butt, Ellis Paine, & Davis Smith, 2008). Scaling up citizen involvement as part of a strategic response to health inequalities requires consideration of what is required to support and value those individuals engaged in delivery. This paper deals with the question of whether involvement through lay health worker (LHW) interventions or more generic volunteering should be supported by payment. Remuneration is an issue that receives inadequate attention in public health policy and research, although practitioners will certainly face choices over incentives and financial support in implementing LHW programmes. The assumption, implicit in much literature, that all participation should be unpaid is questionable, given that public health efforts are often focused on the poorest communities. The aim of the paper is to present a critical discussion of remuneration in the context of the management of LHW programmes, reporting findings from a study of approaches to develop and support lay people in public health roles conducted in England,

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UK (South et al., 2010). Assumptions that a simple distinction can be made between payment and volunteering models are undermined by the variety of approaches to providing financial and nonfinancial benefits that are reported (see Cherrington et al., 2010; Elford, Sherr, Bolding, Serle, & Maguire, 2002; Lam et al., 2003; Leaman, Lechner, & Sheeshka, 1997). Any discussion of LHW remuneration, therefore, needs to take account of the diversity of public health practice. Financial support is an important programme management issue and can be used as a mechanism for achieving various objectives such as addressing poverty or incentivising recruitment (Hooker, Cirill, & Wicks, 2007; Taylor, Serrano, & Anderson, 2001). A World Health Organization review identifies payment as a factor in programme sustainability because most community health workers are poor (World Health Organization, 2007). Boundaries between volunteering and low paid work can be blurred (Baines & Hardill, 2008; The Commission on the Future of Volunteering, 2008); however in the current economic climate, there are legitimate concerns over replacement of paid jobs with volunteer roles (Taylor, Mathers, Atfield, & Parry, 2011). Recompense for time given does not always have to be in the form of a wage, but when payment is involved, anything other than the proper rate for the job can be considered exploitation. Ultimately payment reflects how society values purposeful occupation. Notwithstanding that volunteering is valued as evidence of reciprocity (Dingle & Heath, 2001), it tends to have lower status than professional activity as there is an implicit assumption that reliability and competence is assured through delivery by paid staff. A further issue for public health arises when individuals from low income communities are asked to contribute their time, knowledge and skills freely to help address health inequalities, yet in a context where their personal and employment opportunities are limited due to the impact of structural inequalities (Whitehead, 2007). In summary, financial support for lay delivery raises fundamental matters of fairness, but at the same time, it remains an inherently practical and highly contextualised issue where approaches evolve within policy frameworks that may constrain or facilitate citizen involvement in health. This paper examines these issues through a study focused on public health practice across England, where questions of volunteering and remuneration have not been sufficiently explored. The following section outlines the relationship between motivation and reward in relation to volunteering, before going on to examine how policy frames these issues in England. Volunteering & payments Volunteering has been shown to fulfil of a range of functions (Andreoni, 1990; Benabou & Tirole, 2006), which include providing public goods, investing in human capital and providing volunteers with the means to secure additional extrinsic rewards, or to enable them to exhibit underlying tastes and attributes (such as extroversion or altruism). Exploring the motivations of volunteer firefighters in the US, Carpenter and Myers (2010) distinguish between six discrete behavioural motives for pro-social behaviour such as volunteering: altruism; image concerns; career concerns; making or being with friends; complying with religious beliefs; and excitement/risk seeking. They also identify additional factors influencing volunteers’ decision to participate, including: family tradition; whether or not they have been asked to help; and the payment of extrinsic incentives. While the payment of stipends was found to have a positive effect on the participation rates of some volunteers, for those volunteers prioritising image concerns, such payments could have a negative impact if they were perceived as detracting from an altruistic image. These findings are consistent

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with earlier research (Frey & Goette, 1999), which suggests that paying people to perform a task which they were previously prepared to complete without reward can cause them to reduce their effort. This ‘crowding out’ of intrinsic motivations raises profound challenges to policy makers and practitioners seeking to enhance participation rates and reward those who volunteer. Exploring the motivations of volunteers in a number of different countries, and the impact of external factors, Ziemek (2006) suggests that volunteers will react differently to changes, specifically in the level of contributions made by others, depending on their intrinsic motivation. Ziemek distinguishes between three microeconomic models to explain volunteering, each of which reflects the extent to which the volunteer subscribes to different motivations: the public goods model (where altruism prevails); the private consumption model (where the volunteer derives self-value, for example, in the form of enjoyment, from their contribution); and the investment model (where they pursue an exchange benefit, such as work experience, skills and contacts). She concludes that the level of a country’s economic development positively influences altruism and private consumption motivations, while negatively influencing investment motivation. The Female Community Health Volunteer (FCHV) programme in Nepal, which sought to enhance community self-reliance and empowerment, offers further insights into tensions between economic and social drivers (Glenton et al., 2010). FCHVs were paid a nominal annual stipend, but this was withdrawn after a year of operation due to funding limitations. Ongoing discussions on the re-introduction of payments highlighted the negative impact on volunteers, specifically the unreasonable expectations payments created in communities in relation to the availability and amount of work expected of FCHVs. Payments were also found to have a negative impact on the social respect FCHVs received, in the context of a strong cultural tradition of volunteering. Research into the role of lay tutors on the Expert Patient Programme (MacDonald et al., 2009) suggests that the motivation of these volunteers reflected the importance they ascribed to personal goals and altruism. Nonetheless, volunteers from more deprived areas were less willing to make their contribution for free, suggesting that specific incentives may be required to recruit and retain volunteers from disadvantaged groups. Fuller, Kershaw, and Pulkingham (2008), in a case study of Canadian lone mothers on social assistance, explore the paradox that exists between volunteering as an act of citizenship that demonstrates social worthiness and volunteering as ‘a consequence of the narrowing of liberal notions of social citizenship that once assumed entitlement to a basic minimum standard of living to be a citizenship right’ (p. 168). Here women volunteered in order to gain food or supplement family income through honorariums, but at the same time saw volunteering as an ‘honourable’ act that was linked to altruism and brought greater social inclusion. Drawing on Glucksmann’s theorising of ‘Total Social Organisation of Labour’, which rejects the dualism of ‘paid employment’ and ‘unpaid not-work’ (Glucksmann, 2005), a study of volunteer work in two voluntary sector organisations, one focused on health care and one a community and refugee centre, found interconnections between work in different spheres, both paid and unpaid (Taylor, 2004). Taylor further argues that in order to understand unpaid work, it is necessary to take account of an individual’s social and economic position, as all unpaid work has to be supported economically through some means, for example a partner’s employment or through benefits (Taylor, 2005). In summary, recruiting and maintaining the commitment of volunteers and LHWs requires a sophisticated understanding of the heterogeneous motivations that underpin contributions. Volunteers cannot therefore be treated as a homogenous group, as

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individuals will derive utility from different external stimuli, and will react differently to stimuli such as the offer of payment. Payment, policy and practice in England Lay participation in public health needs to be understood in relation to the political and social context that stimulates demand for active roles. This section explores how the issue of volunteering and payment has been framed in policy relating to England, which formed the context for the study reported here. Volunteerism is widely regarded as a socially and economically desirable activity, and national (UK) governments have emphasised its value to public services, to the economy, to social cohesion and to volunteers themselves (HM Treasury & Cabinet Office, 2007). The act of volunteering continues to be associated with values of altruism and reciprocity, and is distinguished, in policy, from low paid work or unpaid caring roles (Hardill & Baines, 2003; The Commission on the Future of Volunteering, 2008). As part of the Compact agreed between the New Labour government and the voluntary and community sector in England, volunteering was defined as time given unpaid (Compact, 2008). This inevitably placed low paid community work that contributed to societal goals, as performed by some LHWs, outside of policy debates on volunteering. In the latter years of the New Labour government, citizen involvement in service delivery became part of a discourse of democratic renewal (Secretary of State for Communities and Local Government, 2008), but with only scant discussion of state responsibilities for volunteer support. While the Secretary of State for Communities and Local Government (2008:1) praised the third sector’s traditions of ‘purposeful altruism and selfless volunteering’, the problem remained that assumptions about the sustainability of citizen involvement glossed over deep seated inequalities, including the lack of employment opportunities in disadvantaged communities. The election of a Coalition government in 2010, against a backdrop of fiscal crisis, brought renewed emphasis on volunteering and the introduction of the ‘Big Society’ concept, which ostensibly concerned the promotion of social action (Cabinet Office, 2011). The ‘slipperiness’ of the Big Society concept (Hunter, 2011), and the dearth of central government support for the third sector (NCVO Funding Commission, 2010), reflects a non-interventionist stance. There is a threat that citizen involvement, which is conceptualised as predominantly spontaneous activity and certainly unwaged, will be used to cover the retrenchment, fragmentation and privatisation of the welfare state (Community Sector Coalition, 2010). In a period of transition, where public services are also exploring approaches that seek to foster co-production, new service models that incorporate volunteers are emerging (Boyle & Harris, 2009). Choices over which roles attract payment and stable employment are undoubtedly more significant where volunteers form part of a delivery chain that includes paid staff, compared to ‘grassroots’ voluntary organisations built on mutualism and non-hierarchical relationships (Milligan & Fyfe, 2005). Neo-liberal policies sharpen debates about the relationship between volunteering and low paid work; for example, there is a growing critique around unwaged work experience for welfare claimants (Helm & Asthana, 2010). The position advanced in a Charter between Volunteering England and the TUC (Trades Union Congress) (2009) is that volunteering should not be connected with financial reward; neither should it ‘be used to displace paid staff or undercut their pay and conditions of service’. Public health policy in England has skirted round policy conflicts between valuing volunteering and ensuring employment rights are upheld. Despite a broad consensus that community engagement is required to tackle health inequalities, there has been little discussion about how citizen involvement is to be supported in economically disadvantaged communities, where pressures to deal

with personal debt, low income, long-term unemployment or caring responsibilities will shape individuals’ choices to volunteer (Baines & Hardill, 2008). Paradoxically, these are the communities most likely to be targeted for public health interventions. Health policy continues to focus on promoting volunteering as social action that involves a (free) contribution to society (Department of Health, 2011). Yet state support for active citizens is inconsistent; for example, volunteering in governance roles (Institute for Volunteering Research & Volunteering England, 2007) often attracts significant remuneration as recompense for time given. Arguably, ‘Choosing Health’ (Department of Health, 2004), an earlier health strategy of the New Labour government, was the sole public health policy to recognise the potential benefits of linking employment opportunities with community engagement by introducing health trainers, partly as a mechanism to increase skills and employment prospects in disadvantaged communities. Where the lay contribution is narrowly framed within public policy as time freely given, and critical discussion of the merits and disadvantages of financial support does not reach the policy agenda, decisions over remuneration in LHW programmes inevitably become a matter of local discretion. A managerial perspective brings a different set of issues concerning the utility of payment as a device to underpin recruitment and retention (Taylor, Serrano, & Anderson, 2001). Offering pay and potentially stable employment may provide opportunities to develop health careers, but banding LHWs in low paid jobs may also perpetuate disadvantage (Levenson & Gillam, 1998), particularly where development pathways are absent. Choices over financial support may reflect gender inequalities around unpaid caring roles (Hardill & Baines, 2003), or make untested assumptions about the ‘free’ time of certain groups. The dilemma for public health practice is that the management of financial support cannot be easily resolved by greater managerial control, for example placing LHWs into contractual relationships, because this runs counter to the aspiration for greater community and individual empowerment (Witmer, Seifer, Finocchio, Leslie, & O Neil, 1995). Payment is ultimately a complex issue, and this paper explores this through presentation of results on the theme of payment drawn from a study on LHW roles. Methods The study aimed to investigate approaches to develop and support lay people taking on public health roles, with a focus on the then public health priorities in England: health inequalities, smoking, obesity, physical activity, alcohol, sexual health and mental health (Department of Health, 2004). For the purposes of the study, LHWs were defined as individuals without a professional education or background, who take on identified public health roles and are supported by professionals. The study was conducted in England, UK, between 2007 and 2009 in two phases and drew on research-based evidence together with practice-based evidence. The study received NHS (National Health Service) ethical approval from the Leeds (West) Research Ethics Committee. Phase 1 Phase 1 comprised three elements whose objectives were to identify and critically analyse models of how public health services recruited and supported LHWs (see South et al., 2010 for further details): (i) A systematic scoping review of relevant published and grey literature was undertaken. Following a systematic search and selection process, 224 papers were included in the review, and data extraction was undertaken across categories

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relating to intervention, population, study design and process issues, including payment. The scoping review resulted in a map of the literature and a narrative review. (i) Three public hearings were held using deliberative methods within a public forum to explore contested areas with experts drawn from different fields. Fourteen presentations of oral evidence were made at the hearings. Framework analysis was used to analyse the results (Ritchie, Spencer, & O’Connor, 2003). (iii) A web based register of interest was established where health projects involving LHWs in England were invited to record information across a number of fields that broadly matched the data extraction fields used in the review. Of the 41 projects that registered, 22 were deemed to be directly relevant to the scope of the study. Phase 2 Case studies were undertaken to examine the process issues identified in Phase 1 in greater depth, and to gather perspectives from those with experience of LHW programmes. A multiple case study design (Yin, 2009) investigated the phenomenon of lay roles in the social contexts where LHWs operated. Naturalistic methodology was used to understand roles and relationships within those social contexts and to retain flexibility to pursue lines of investigation (Patton, 2002). Each case study attempted to gain a holistic view of how approaches worked in practice using qualitative, interview-based methods exploring the perspectives of stakeholders. The scope of the interviews was informed by Phase 1 and topic guides were developed to allow individuals to discuss their personal experiences and views on LHW roles. Payment was one of the topics covered and interviewees were also asked open-ended questions about LHW support needs. The interviews and focus groups with service users covered a smaller range of topics and focused primarily on perceptions of roles and the acceptability of LHWs (see South, Kinsella, & Meah, 2012). The sampling strategy had two elements: the selection of case study sites and the construction of a sample within the cases. Projects were selected to illuminate the different models identified in Phase 1 and additionally to demonstrate variation across health focus, population and host organisation. Within each project, a

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sample was constructed based on individuals’ current or past involvement and to ensure variation of roles, including public health commissioners, managers, practitioners, health professionals, LHWs and service users receiving support through the programmes. The priority for sampling was to gather sufficient data to produce explanations about processes within each case and to ensure lay perspectives were included. Participants who were unwaged were offered a shopping voucher following the completion of the interview to acknowledge their contribution of time. In total, 136 individuals were interviewed (Table 1). All interviews were recorded on digital recorders and later transcribed verbatim. Data analysis was conducted in line with the principles of qualitative thematic analysis (Mason, 1996), first describing and understanding the cases prior to building explanations across multiple case studies (Yin, 2009). Data organising and indexing was carried out to develop an initial thematic framework, using NVIVO software. Individual case study reports that summarised themes and described context were then prepared, allowing for cross case analysis, where themes were mapped onto a matrix (Miles & Huberman, 1994). The final stage was the production of a narrative synthesis that involved an iterative process to build explanations. Thematic analysis of service user interviews used a similar process but was conducted separately (South et al., 2012). Three researchers were involved throughout the data analysis process in order to increase reliability, and other members of research team who had been involved in individual case study reports were able to authenticate the accounts produced. Payment emerged as a major thematic category that demonstrated complexity. This paper presents findings on how payment was perceived and managed in the unique context of each case (Yin, 2009), and also reports interpretive themes that were identified through the cross case analysis (Miles & Huberman, 1994). Quotations are used as illustrative of themes (Mason, 1996), except where divergent views are reported as indicated in the text. Findings Models in practice Of the 224 publications reviewed in Phase 1, only a minority contained any discussion of remuneration as a process issue. Whether roles were paid or not was identified as one of the

Table 1 Case study projects and sample of participants. Case study

Public health focus

Role type

Payment

Sample (number)

Breastfeeding peer support

Breastfeeding uptake

Peer support: LHWs offer support & advice on breastfeeding

Waged and volunteer LHW roles

Staff (5) LHWs (9) External partners (6) Service users (11)

Community Health Educators

Nutrition & physical activity.

Bridging: LHWs engaging disadvantaged communities through health education, informal support and group activities.

Sessional payment per hour

Staff (10) LHWs (9) External partners (2)

Neighbourhood health project

Health & wellbeing

Community organising: LHWs involved in design and delivery of community based activities

No

Staff (4) LHWs (6) External partners (4) Service users (15)

Sexual health outreach

Uptake of screening with men who have sex with men

Peer education: LHWs involved in health education and outreach

No

Staff (6) LHWs (3) External partners (3)

Walking for Health scheme

Physical activity

Peer support: LHWs independently lead health walks & support participants

No

Staff (10) LHWs (10) External partners (3) Service users (20) Total participants n ¼ 136

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dimensions of difference in categorising LHW interventions. Nonetheless, choices over remuneration varied even within specific intervention models; for example, Jackson and Parks (1997), in their review of 87 Lay Health Advisor programmes, found that over half paid their LHWs. Examples of interventions that offered alternative forms of financial incentives or support included: gym membership for opinion leaders recruited for an HIV prevention intervention (Elford et al., 2002); payment for attendance at training in a peer education intervention for homeless people (Hunter & Power, 2002); and financial incentives for LHWs successfully recruiting to a cervical screening programme (Lam et al., 2003). Out of 22 projects on the register of interest, eight had paid lay workers, five involved people on an unpaid, voluntary basis and nine did not record information. In addition to findings on patterns of practice, remuneration emerged as a contested issue in terms of lay experiences and programme management. Discussion on payment, welfare benefits and the challenges of managing expenses in the context of an overly bureaucratic health service threaded through all the three public hearings (South, Meah, & Branney, 2011). Concerns over conflicts with welfare benefit rules were also raised at the public involvement event held with volunteers prior to those hearings. These matters were explored in greater depth in the five case studies of public health projects, which represented contrasting approaches to remuneration (Table 1). The following sections examine perspectives on payment and volunteering drawn from the case studies, and the public hearings where relevant. Volunteering and rewards The social benefits associated with participation was a cross cutting theme in the three case studies based on volunteerism. In the sexual health outreach project, where volunteers worked alongside staff but within clearly defined roles, payment was not a major topic of discussion. While there was no financial support offered, social rewards occurred through enjoyment of the volunteering experience and activities where staff and volunteers socialised together: “We only get expenses, there is no financial reward whatsoever, I just do it because I enjoy it.” (Volunteer, sexual health outreach) In the neighbourhood health project, volunteers spoke of health and social benefits derived from involvement alongside an altruistic commitment to their community. The project was located in a disadvantaged housing estate but volunteers, most of whom were retired or unable to work, did not regard being unpaid as a problem. The issue of payment was raised by a minority of stakeholders; one external partner advocated for introduction of payment to support retention and a service user observed that the volunteers were “putting lots of hours in and it seems a shame that they don’t get anything for what they do”. The case showed how volunteering signalled commitment to a community, but paradoxically financial rewards could indicate the perceived value of that contribution, as illustrated by a volunteer talking about paying for social events: “Maybe they [the council] should say thank you for all the time you volunteer for us and say, you know, take them out, give them a Christmas lunch. Yeah. It’s not so much a reward, more like a thank you, you know what I mean? Yeah, all the good work that they’ve done over the year and that sort of thing. [.] No, we go out for a Christmas lunch [with the project] and you’ll pay for yourself.” (Volunteer, neighbourhood health) Appropriate boundaries for unpaid work also emerged as a theme in the walking for health case. Walk leaders’ responsibilities

were seen as considerable, some individuals reportedly devoting considerable time to the role. Distinguishing between paid work and volunteering remained important, for example, one service user commented that “there is only so much free time you can give for nothing” and added “to take it that much further you need that financial reward to say yes this is a job effectively”. A divergent perspective was provided by one walk leader who found it difficult to explain the volunteer role to her walk participants as “they think it’s not the case that nobody would do something for nothing”. Remuneration supporting engagement Two case studies utilised payment for LHW roles. In the breastfeeding peer support case there were two types of role, with the higher level of responsibilities and more extensive training associated with paid employment. Having these two roles was seen as valuable, for while paid LHWs brought greater reliability and accountability, and payment provided incentives for people to maintain involvement, volunteers brought flexibility and passion: “So for me having both paid and unpaid . people can then have a choice of what level of support that they offer to the organisation and how involved they get . And often more real as well, you know, you’ve got women who are volunteering . because they are passionate about it, not necessarily because they’re being paid, which I think often brings a completely different dynamic. People get away with asking different questions than they would if you’re a paid worker and making different challenges.” (External partner, breastfeeding peer support) The community health educator project illustrated a less traditional approach to remuneration, as LHWs were paid an hourly sessional fee but retained flexibility in terms of when and how much they worked. In this case, sessional payment was regarded very positively as a strategy to engage individuals from disadvantaged communities. For community health educators, these payments had multiple benefits, ranging from acknowledgement of the value of the contribution (“the rate I got paid was fantastic . it made you feel even more wanted and worthy”), through to removing financial barriers to participation (“I have to survive; it’s important that I have something to take away”). Mutualism and reciprocity were strong themes in this project, as in the other case studies. The approach of providing financial support to LHWs from low income communities did not appear to affect altruistic motivations, nor alter the perception that community health educators had of themselves as individuals fulfilling a role within their community: “I find that I have other things to do that mean really I don’t want to see it as a wage, I don’t want to see it as doing so many sessions a week so that I get paid so much money. So I’m not looking at it as a sort of a paid job it’s just something extra to do besides the voluntary work.” (Community health educator) Payment was seen by respondents as an enabling mechanism, but it inevitably raised the programme costs, making this a more expensive option for commissioners. An emerging theme was the fairness of a standardised pay rate, given that there was significant variation in the capabilities of individual community health educators and the degree of responsibility assumed by them in their activities. Potential conflicts with welfare benefits systems were also acknowledged, where the responsibility to declare additional payments was seen to pose an additional barrier to involvement in low-income communities, confirming themes from the public hearings:

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“So, we’ve got single mothers who can earn up to £20 a week.On occasions we’ve had health educators ring up and say, ‘Oh, I’ve had my benefits stopped because, you know, I’ve earned £90 this month’.So that’s always a bit of a logistical nightmare.” (Staff member, community health educators)

Expenses and costs Volunteering guidance points to the importance of ensuring out-of-pocket expenses are paid (Hawkins & Restall, 2006), and all the case study projects had systems in place to facilitate this. Nonetheless, it was found that expenses were not always claimed, even in areas of economic disadvantage. There were many examples where individual volunteers were absorbing personal costs of volunteering or attracting additional costs in supporting others to participate. Potential costs included travel, refreshments, entrance fees, mobile phone calls, publicity and childcare. Reasons for not taking up legitimate expenses sometimes puzzled project staff. It was suggested that some volunteers made choices because they did not view costs as significant, or find systems easy, as typified by this example: “I’d bought juice and biscuits when we ran out and I replaced them and then I had a £10 receipt and I had to actually ask [name] and [name] who I would give that to because I had no idea. As it happens, I’ve lost the receipts, so I’m not going to claim it anyway. And I’m not, I’m not actually bothered about ten quid.” (Volunteer, breastfeeding peer support) Bureaucratic hurdles to claiming expenses were also identified as problematic in the public hearings. This had led some expert witnesses to develop systems to provide immediate reimbursement, or alternatively to pay out of their own pocket because, as one asserted, “it is not worth the hassle in the NHS to get the money back”. One audience member explained that “we are dealing with people who’ve got no dosh at all, so they can’t lay out the money”. In the walking for health case study, a previous expenses system had addressed some of these issues, as explained by a staff member: “So what we felt was that if we paid expenses which was just £10 per walk it would show that we valued them and there’s a lot more involved in terms of getting to the walk, getting home from the walks, doing the checks, making sure that you have water and walk leaders had to make sure that they had two bottles of water one for themselves and one extra, all that kind of stuff.” (Staff member, walking for heath) This small payment had later been withdrawn because of a new district volunteer policy and a minority of volunteer walk leaders interviewed were unhappy with the change as they reported hidden costs that were difficult to claim back. Discussion The study findings confirm that financial support is a common feature of LHW programmes, but it cannot be conceptualised as a simple dichotomous state: either pay associated with employment status or volunteering as ‘time freely given’. Instead there is a variety of means and multiple motivations for both offering and receiving such support, thus fitting with sociological understandings of the interconnectedness of paid and unpaid work (Glucksmann, 2005; Taylor, 2004). The findings call into question whether all lay activity in public health should be necessarily

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subsumed within a volunteering framework. Altruism, commitment to a community and social rewards for the giver as well as the beneficiary were cross cutting themes, regardless of financial support and these themes are echoed in other research with those at the margins of employment (Baines & Hardill, 2008; Fuller et al., 2008). Having conducted only five in-depth case studies e albeit representing contrasting public health projects e it is impossible to generalise from the findings. More research is needed to evaluate the acceptability and utility of alternative approaches to remuneration across types of public health programme, and in different socio-cultural and economic contexts. From a reflexive stance, the research team were sensitised to the significance of payment as a dimension of difference through the scoping study, but the case studies led to a broader set of themes. Individual choices appear to be contingent on a range of factors, including programme approach, community needs, individual circumstances and values, emphasising the importance of social context (Glenton et al., 2010; Wilson, 2000), as well as behavioural motives (Carpenter & Myers, 2010), in understanding volunteering. The study revealed some of the economic elements of citizen involvement, such as personal costs and benefits, which may help with assessing cost effectiveness (Mason, Carr Hill, Myers, & Street, 2008). Without robust systems of reimbursement, those on low incomes cannot easily absorb the inevitable costs associated with volunteering. Priority must be given to swift and full reimbursement of LHW expenses with minimum bureaucracy, or alternatively arrangements for payment prior to participation. Promoting equity was a motivation for professionals when engaging LHWs in the context of economic disadvantage and this is an area where there has been little research. The findings suggest that factoring in financial support can address social determinants by providing additional income to support engagement. Determining the level of remuneration is challenging, because it raises the question of ‘what is a fair rate?’. The community health educator case study highlighted some of the complexities of payment systems for volunteer work in low-income communities. Sessional payment may be insufficient to meet economic need and subsequently undermine commitment to a programme (Coufopoulos, Coffey, & Dugdill, 2010; Leaman et al., 1997). The sexual health outreach project was the only case study where material disadvantage was not a defining feature of the community of interest and this is perhaps an explanation of why social rewards were emphasised and financial support was discussed only superficially. Fairness was an interpretive theme associated with role boundaries and the extent of commitment both demanded and offered by LHWs. The findings suggest that social value is linked to financial value, but this is not a simple relationship. Payment did not appear to ‘crowd out’ intrinsic motivations, and this finding differs from other studies (Carpenter & Myers, 2010; Frey & Goette, 1999). Wilson (2000) critiques exchange theories predicated on rational choices over the costs and benefits of volunteering, because individuals may gain benefit without this being the primary reason for volunteering. Some participants in our study suggested that LHW activity should attract some financial reward to demonstrate that the lay contribution is valued. Conversely, there is a risk that the independence and flexibility brought by volunteers, who are not in a contractual ‘work-like’ relationship (Gaskin, 2003), will be undermined if a pay structure is introduced (Witmer et al., 1995). One witness at the public hearings spoke of how payment could alter the ‘dynamic’ between a LHW and their community. Notwithstanding that inappropriate professionalisation can arise with both paid and unpaid lay roles (Jackson & Parks, 1997), the findings confirm the experience of Cherrington and colleagues that payment is linked to expectations of greater reliability and control (Cherrington et al., 2010).

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Clearly while expecting all social action to be paid would be unrealistic and introduce unnecessary regulation, there needs to be robust debate about why some LHW roles might be associated with employment, and where that line should be drawn. There are also alternative systems of non-monetary rewards that bypass the limitations of formal employment or unpaid volunteering. For example, time banking provides a framework for participants to give and receive services using the ‘community currency’ of time credits (Seyfang, 2006); this can work on a reciprocal basis ‘neighbour-to-neighbour’, or between individual and organisation where volunteers earn privileges such as trips (Marks, 2012). While time banks have a role in the development of mutual aid in disadvantaged communities, Seyfang (2006) cautions that policy conflicts occur where the welfare system continues to value formal paid employment above volunteer work. The study explored questions around professional support for LHWs. Choices over remuneration were found to be highly contextual, therefore require reflective professional practice and negotiation with communities. Where payment is not regulated in the same way as within employment structures, this may generate complications, as illustrated by the community health educator project where there were variations in LHW responsibilities. Taylor et al. (2001) report on a US peer education nutrition programme where the offer of payment, despite being a motivating factor in recruitment, provided perverse incentives to finish the training quickly or recruit individuals who did not match the criteria. The authors conclude that a pay structure needs to be ‘detailed, written, explained, equitable, and designed so that potential abuse is minimized’ (p.289). Overall the findings indicate the need for common sense protocols on payment, which are adaptable to local context, in order to facilitate involvement. While experienced community practitioners manage these aspects, they should also be addressed systematically in commissioning volunteer support through organisations with the necessary expertise (South, White, & Gamsu, 2013). Lessons can be drawn from the voluntary and community sector, which has greater experience of managing these matters, in comparison with public and private services where volunteer models are less common. The need for financial support for LHWs drawn from economically disadvantaged communities remains an issue for public health (World Health Organization, 2007), and is ultimately a policy problem in need of a solution. In our study, the welfare benefits system in England was perceived as insufficiently flexible to support easy reimbursement, and this may therefore distort how statutory services develop relationships with volunteers. There is evidently scope for practitioners to collaborate with welfare benefits advice services when instigating LHW programmes, especially given the increasing financial hardship in some communities. More broadly, policy conflicts need addressing where neo-liberal policies exhort the unemployed to volunteer to become more employable, but create a climate where claimants risk reduction of income when they do. Transitions in welfare systems, driven by global economics, may ultimately have a profound impact on the relationship between volunteering and payment in LHW programmes and this is a topic for future research. Concluding remarks Payment in LHW programmes is a complex issue and this paper has contributed to understandings of the range of extrinsic and intrinsic motivations underpinning professional and lay choices over financial support. Without an understanding of lived experiences, costs of participation may remain hidden and work undervalued. Some means to manage personal costs have been identified, but more research is needed to assess the effectiveness, equity and acceptability of different models of financial support in different

countries and contexts. The implications for practice are that rewards, whether financial or social, require active management, however, choices made should not undermine LHWs’ connection to their communities. We have questioned assumptions that all lay involvement should necessarily be equated with volunteering. Strategies to incentivise and recognise effort, to reimburse costs and to enhance employability through the use of payment are appropriate when working with economically disadvantaged communities. Inevitably such strategies become a matter of local discretion when the policy framework focuses almost exclusively on the notion of volunteering as time freely given. Evidence presented here brings a new emphasis on the means to achieve fairness and reflect social and economic value of volunteer work within LHW programmes. Health policy therefore needs to adopt a model of citizen involvement that acknowledges mutualism and reciprocity can co-exist with financial support systems. Furthermore, in a period of retrenchment of public services, the public health community needs to advocate for employment rights alongside the value of participation. Acknowledgment/s This work was supported by the National Institute for Health Research Service Delivery and Organisation Programme (project number 08/1716/206). The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Department of Health. The authors would like to thank Dr. Angela Meah, Rebecca Jones and Karina Kinsella for their contribution to data collection and analysis. References Andreoni, J. (1990). Impure altruism and donations to public goods: a theory of warm-glow giving. Economic Journal, 100, 464e467. Baines, S., & Hardill, I. (2008). ‘At least I can do something’: the work of volunteering in a community beset by worklessness. Social Policy and Society, 7, 307e317. Benabou, R., & Tirole, J. (2006). Incentives and pro-social behaviour. American Economic Review, 96, 1652e1678. Boyle, D., & Harris, M. (2009). The challenge of co-production: How equal partnerships between professionals and the public are crucial to improving public services. London: National Endowment for Science, Technology and the Arts, New Economics Foundation. Cabinet Office. (2011). Building the Big Society. http://www.cabinetoffice.gov.uk/ sites/default/files/resources/building-big-society_0.pdf Accessed 21.11.13. Carpenter, J., & Myers, C. K. (2010). Why volunteer? Evidence on the role of altruism, image and incentives. Journal of Public Economics, 94, 911e920. Cherrington, A., Ayala, G. X., Elder, J. P., Arredondo, E. M., Fouad, M., & Scarini, I. (2010). Recognizing the diverse roles of community health workers in elimination of health disparities: from paid staff to volunteers. Ethnicity & Disease, 20, 189e194. Community Sector Coalition. (2010). Unseen, unequal, untapped, unleashed: The potential for community action at the grassroots. London: Community Sector Coalition. Compact. (2008). Volunteering: A code of good practice. London: Compact Voice, Cabinet Office, Commission for the Compact, Local Government Association. Coufopoulos, A., Coffey, M., & Dugdill, L. (2010). Working as a community food worker: voices from the inside. Perspectives in Public Health, 130, 180e185. Department of Health. (2004). Choosing health. Making healthier choices easier. London: The Stationary Office. Department of Health. (2011). Social action for health and well-being: Building cooperative communities. Department of Health strategic vision for volunteering. Leeds: Department of Health. Dingle, A., & Heath, J. (2001). Volunteering matters e or does it? A UK parliamentary study of the role of voluntary action in the twenty-first century. Voluntary Action, 3, 11e25. Elford, J., Sherr, L., Bolding, G., Serle, F., & Maguire, M. (2002). Peer-led HIV prevention among gay men in London: process evaluation. AIDS Care, 14, 351e360. Frey, B. S., & Goette, L. (1999). Does pay motivate volunteers?. Working Paper Series, No. 7. Zurich: Institute for Empirical Research in Economics. Zurich: University of Zurich. Fuller, S., Kershaw, P., & Pulkingham, J. (2008). Constructing ‘active citizenship’: single mothers, welfare and the logic of voluntarism. Citizenship Studies, 12, 157e176. Gaskin, K. (2003). A choice blend: What volunteers want from organisation and management. Institute for Volunteering Research.

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