Introduction
In many welfare states, local governments are facing a critical public management challenge: they must invent and organize new modes of social service delivery while simultaneously addressing severe budget cuts. In response, they ‘reach out’ and aim to coordinate service delivery processes in which third sector organizations fulfil an increasingly important role (Pestoff et al. Reference Pestoff, Brandsen and Verschuere2013; Verschuere et al. Reference Verschuere, Brandsen and Pestoff2012; Osborne Reference Osborne2010; Evers Reference Evers1995). As a result, in many countries, the ‘traditional’ welfare state has effectively transformed into what is referred to by some as a state of agents (e.g. Heinrich et al. Reference Heinrich, Lynn and Milward2009), or by others as third-party governance (e.g. Piatak et al. Reference Piatak, Mohr and Leland2017). Although it remains a key task for local governments, their role has shifted from that of direct service deliverer to facilitator of social support. Policymakers also urge individuals in need of social support to decrease the use of publicly funded services as much as possible and to take on a more active responsibility for their personal welfare problems (Wright Reference Wright2016; Pavolini and Ranci Reference Pavolini and Ranci2008). Individuals are now expected to seek alternative forms of support from a wide variety of third sector organizations, ranging from human service associations and social welfare organizations to various types of citizen initiatives (neighbourhood projects, online social support platforms, co-operatives, etc.) (Pestoff et al. Reference Pestoff, Brandsen and Verschuere2013).
However, even if sufficient social services are offered by these third sector organizations, we cannot assume that individuals in need of support actually ask for them. For example, a woman suffering from severe rheumatism and feelings of loneliness may refrain from asking for help from a social welfare organization. An elderly man may be unaware of a meal service, which is offered by local residents on an online platform. Or a man who is going through a divorce and is confronted with various problems may find it difficult to ask for help from an organization that offers emotional and administrative support. These are three examples, out of many, of individuals who—albeit under different circumstances and for different reasons—are unable to effectively utilize available sources of social support. Despite its apparent universality, our empirical and theoretical understanding of this phenomenon, which we refer to as the non-take-up of social support, is still limited. This is problematic, because failure to understand and effectively address non-take-up leaves social needs unattended to. Moreover, non-take-up may lead to higher social welfare costs in the long run, as individuals may develop even more serious problems that require more (professional) attention. To improve our understanding of this phenomenon, we will investigate the determinants of non-take-up of social support. Our central research question is, therefore, the following: how can non-take-up of social support be explained?
We proceed in two steps. First, we distil potential explanations for non-take-up of social support from social-psychological, socio-epidemiological, socio-cultural, and public administration research. Although each discipline offers a wealth of information about the determinants of help-seeking behaviour in various contexts, this knowledge is rarely directly related to the specific phenomenon of non-take-up of social support. Additionally, these academic disciplines have developed rather separately over time and, while differing in many respects, they also (though often implicitly) show some overlap. As we will argue, to better understand this phenomenon it is necessary to move towards a more integrated perspective. Therefore, based on the relevant strands within the academic literature, an important objective of this paper is to provide a more comprehensive understanding of the main reasons why individuals refrain from asking for social support from third sector service providers. Our approach resonates with the case Robert Dahl made back in 1947, when he ‘(…) argued that public administration must work together closely with fields that focus on human behaviour in other areas, including psychology and sociology’ (Grimmelikhuijsen et al. Reference Grimmelikhuijsen, Jilke, Olsen and Tummers2017: 3).
Second, we examine the extent to which we find empirical evidence for these determinants based on the narratives (interviews) of 55 individuals and two focus groups (n = 16) in the Dutch municipality of The Hague (500,000 + inhabitants). Given the challenging nature of recruiting interviewees from this ‘hidden or hard-to-reach population’ (Shaghaghi et al. Reference Shaghaghi, Bhopal and Sheikh2011), we selectively sampled at different locations where individuals, perforce, come to meet their other help needs. In our study, these locations are the emergency room of a local hospital, different locations of the food bank and the offices of social work councillors. The two focus groups were organized to further our understanding of reasons for non-take-up (Morgan Reference Morgan1996) and to strengthen the internal validity of our study.
This study is, to the best of our knowledge, the first to empirically investigate the non-take-up of social support, using an approach that encompasses insights from different—and hitherto largely separated—academic disciplines. The study does not claim to be exhaustive, however. Rather, we aim to develop directions for further theoretical refinement and empirical investigation of the determinants of non-take-up. Therefore, we conclude our article with a discussion of the implications of our findings, we evaluate its limitations and propose new research avenues.
Theory: Determinants of Non-take-up of Social Support
In this section, we present the current state of knowledge in the academic literature on the potential determinants of non-take-up of social support. We summarize these determinants based on social-psychological, socio-epidemiological, socio-cultural and public administration research.
Social-Psychological Research
This line of research is characterized by its focus on personal psychological barriers and the ambivalent, often conflicting emotions that individuals have when deciding whether or not to ask for help (Nadler Reference Nadler, Deaux and Snyder2012; DePaulo Reference DePaulo, DePaulo, Nadler and Fisher1983). Several theoretical frameworks have been developed to explain (non-)help-seeking behaviour (Cohen Reference Cohen1999), of which reactance theory and the threat to self-esteem model are most relevant for our specific research purposes.
The central assumption of reactance theory is that individuals want to retain their freedom of choice and that a perceived loss of freedom leads to a negative psychological state: reactance (Miron and Brehm Reference Miron and Brehm2006; Brehm and Brehm Reference Brehm and Brehm1981). It further states that individuals are motivated to redress a threat to—or an actual loss of—freedom. When applied to help-seeking behaviour, this theory suggests that negative feelings towards potential helpers—and resistance towards their efforts to help—may arise as a result of a (perceived) loss of freedom and (perceived) dependence on a source of help (Gross et al. Reference Gross, Wallston and Piliavin1979). As Gross, Wallston, and Piliavin state: ‘(…) reactance and associated negative feelings towards assistance should be greatest when help is arbitrarily and externally imposed and least when the recipients have maximum choice regarding when, where, and how they are helped’ (Reference Gross, Wallston and Piliavin1979: 300). Mazelis (Reference Mazelis2017), in her research of the role of social ties within privates safety nets of the poor in America, also finds that this feeling of independence plays a prominent role. She states: ‘For many participants, forging ties with others and getting assistance with daily needs poses a threat to their sense of independence’ (Mazelis Reference Mazelis2017: 62). Although this work focuses on help-seeking within private safety nets, we contend that an individual’s sense of independence should also be considered in the context of third sector organizations.
The second framework is the threat to self-esteem model, developed in the 1980s and has been empirically validated over time (Nadler Reference Nadler1987, Reference Nadler, Deaux and Snyder2012, Reference Nadler, Schroeder and Graziano2015). This model ‘(…) assumes explicitly that self-related consequences of aid are critical in determining the recipient’s reactions’ (Fisher et al. Reference Fisher, Nadler and Whitcher-Alagna1982: 38). Summarizing this model, Wang (Reference Wang2002) states that asking for help is a mix of self-supportive elements (e.g. being able to solve problems) and self-threatening elements (e.g. feelings of failure, dependency, inferiority). Specific aspects of the context may highlight one set of elements over the other and determine if help-seeking is experienced as self-supportive or self-threatening. To the extent that this is associated with self-threatening elements, Wang continues, it is likely to invoke a cluster of negative defence reactions, such as unfavourable donor evaluations and low help-seeking behaviour. In other words, individuals make an implicit cost/benefit analysis of their self-esteem when they consider whether to ask for help (Cohen Reference Cohen1999).
A third theoretical framework that we identified within the social-psychological literature, is equity theory. This was originally developed as a general theory to explain social behaviour and was later also applied to explain helping behaviour in the context of individual social networks (e.g. Walster et al. Reference Walster, Berscheid and Walster1973). Its main assumption is that individuals want to maintain equity in their interpersonal relations and are discomforted (i.e. experience negative arousal) when they experience inequitable relations. In the context of helping relations, this means that equality in the relationship between the helper and the recipient, feelings of indebtedness, and the principle of reciprocity are all important elements (Cohen Reference Cohen1999; Walster et al. Reference Walster, Berscheid and Walster1973). However, this particular theoretical framework is outside the scope of our research context, as it focuses on the context of individual social networks instead of that of third sector organizations.
Socio-Epidemiological and Socio-Cultural Research
Socio-epidemiological and socio-cultural research further contribute to our general understanding of help-seeking behaviour. Both emphasize the role of the broader social context. More particularly, the former discipline focuses on the relationship between social-structural factors and individual helping behaviour (e.g. van Groenou et al. Reference van Groenou, Glaser, Tomassini and Jacobs2006; Asser Reference Asser1978). The latter concentrates on the impact of cultural norms and values on individual help-seeking behaviour (Nelson-Le Gall Reference Nelson-Le Gall1985; Fishbein and Ajzen Reference Fishbein and Ajzen1975). We derive several insights from these two streams of literature.
The first crucial contribution is that epidemiologists conceive helping behaviour as a process, differentiating between different phases of help-seeking. Rickwood et al. locate the help-seeking process ‘(…) at the nexus of the personal and the interpersonal’ (Reference Rickwood, Deane, Wilson and Ciarrochi2005: 8). This means that individuals first have to be personally aware of (and acknowledge) their symptoms as relating to a welfare problem that needs to be solved. Subsequently, individuals must—at the interpersonal level—be able to articulate their help needs to (potential) providers of help. If an individual is unaware of available support or perceives it as being unavailable, then this impedes help-seeking (Rickwood et al. Reference Rickwood, Deane, Wilson and Ciarrochi2005). Epidemiologists also contribute by investigating the role and importance of the knowledge and abilities in help-seeking behaviour. This pertains to digital and linguistic proficiencies (cf. Sannen Reference Sannen2003), health literacy (cf. Gulliver et al. Reference Gulliver, Griffiths and Christensen2010), social skills, and knowledge about (the availability of and eligibility for) support provisions (cf. Childers Reference Childers1975). Whereas interesting research is conducted into how such knowledge and skills matter for (non-)help-seeking for professional medical services (e.g. Andersen Reference Andersen2008) and mental health services (e.g. Pescosolido et al. Reference Pescosolido, Boyer, Medina, Aneshensel and Phelan2013), there is a need for more research regarding (non-)help-seeking of social support from third sector organizations. In sum, what is to be learned from socio-epidemiological research is that even when individuals recognize their personal welfare problem, acknowledge the need for support, and want to seek help, there can still be many potential obstacles in various phases throughout the help-seeking process.
Socio-cultural research aims to understand how individuals are socialized—through culture, ethnicity, gender—and how this influences their helping behaviour. From this perspective, ‘individuals could be expected to differ in the tendency to seek help as a function of the degree to which they have internalized these societal norms and values’ (Nelson-Le Gall Reference Nelson-Le Gall1985: 57), which is why this perspective is also known as the social-normative approach. For example, a study of adolescents’ decisions to seek professional help for mental health problems indicates that cultural factors, such as family obligations, play an important role in help-seeking behaviour (Guo et al. Reference Guo, Nguyen, Weiss, Ngo and Lau2015). Additionally, different studies of help-seeking for community health and social services find that these services are underutilized by some ethnic minority groups compared to the rest of the population (see Howse et al. Reference Howse, Ebrahim and Gooberman-Hill2004).
Lastly, Linders (Reference Linders2010) finds that so-called feeling rules play a role in individual helping behaviour for social support. This concept stems from the work of Hochschild (Reference Hochschild1979) and refers to the social conventions that ‘prescribe’ to individuals what they are supposed to feel in a specific situation. Feeling rules thus act as social guidelines. This implies, for instance, that social convention ‘prescribes’ that one can ask someone for instrumental help, such as chores in and around the house, but one feels inhibited to ask that person for more intimate forms of help, such as personal care (Linders Reference Linders2010, see also Vreugdenhil Reference Vreugdenhil2012). These findings stem from research on help-seeking for informal care (help from family, friends, neighbours) and are still quite tentative. This study will further explore whether and how feeling rules affect help-seeking for social support services from third sector organizations.
Public Administration Research
Public administration research on non-take-up is mostly focused on governmental bureaucracies that distribute all sorts of social security benefits, such as child support grants, healthcare insurance programs (e.g. Medicaid) and unemployment benefits (Heinrich Reference Heinrich2015; Brodkin and Majmundar Reference Brodkin and Majmundar2010; Hernanz et al. Reference Hernanz, Malherbet and Pellizzari2004; Van Oorschot Reference van Oorschot and Andress1998). This line of research attempts to understand the role and effect of obstacles in transactions, or ‘bureaucratic encounters’ (Kahn et al. Reference Kahn, Katz and Gutek1976), between eligible welfare clients and (representatives of) government bureaucracies. Such encounters do not always run smoothly and may be negatively affected by a wide array of bureaucratic obstacles, which is well documented in the public administration literature (see, e.g. Tummers et al. Reference Tummers, Bekkers, Vink and Musheno2015). Only scant attention, however, is paid to how bureaucratic barriers (may) thwart access to and utilization of support provisions from third sector organizations (Salamon and Sokolowski Reference Salamon and Sokolowski2016) in the social domain, such as human service associations, welfare organizations, neighbourhood projects and citizen co-operatives.
These third sector organizations have become an integral pillar of the system of social service delivery (Brandsen and Pape Reference Brandsen and Pape2015; Henriksen et al. Reference Henriksen, Smith and Zimmer2012; Brandsen and Pestoff Reference Brandsen and Pestoff2006). They offer all kinds of provisions, which are intended to strengthen the self-reliance of individuals and support them in coping with their personal welfare problems. Furthermore, in many countries policymakers explicitly expect individuals to turn to these third sector organizations first, before seeking other, more expensive forms of support. In other words: in the eyes of policymakers, third sector organizations play a crucial role in curbing social welfare expenditure. In light of this, identifying potential bureaucratic barriers in this particular help-seeking context is highly relevant. To structure our discussion, we make an analytical distinction between different types of bureaucratic obstacles that may occur, respectively, at the individual level, the organizational level and the level of the welfare system as a whole. To visualize these different levels, as well as the actors involved, we include a customized version of the multi-level analytical model that has been developed by Van Oorschot (Reference van Oorschot and Andress1998) in order to explain non-take-up of social security benefits (see Fig. 1).
Multi-level influences on non-take-up of social support.
Regarding bureaucratic obstacles at the local welfare system level, help-seeking can be hindered by inadequate information about services, a fragmented service supply, and a disconnection between the supply of and demand for services (Sannen Reference Sannen2003). Often a wide array of social services is (freely) available, but when information about those services falls short and does not reach the target group, this negatively affects take-up. Secondly, fragmentation of service provision can cause confusion and may obscure the actual supply of services. And additionally, when services are not tailored to—personal, and sometimes highly specific—support needs, this may (further) diminish the likelihood that they will be utilized.
At the organizational level, a variety of bureaucratic thresholds may obstruct the utilization of social support offered by third sector organisations. Sannen (Reference Sannen2003) identifies entry conditions and waiting lists for services as potential barriers. The former refers to individuals having to meet certain eligibility criteria (e.g. household income and place of residence) and having to complete entry procedures (e.g. intake interviews and application forms). More generally, complicated rules and procedures may reduce the accessibility of social services and may even lead to administrative exclusion. Brodkin and Majmundar (Reference Brodkin and Majmundar2010) show that both formal and informal organizational practices can add hidden costs to claiming social security benefits to the extent that they are complicated, confusing, or cumbersome. They also find that ‘(…) organizational practices had unequal effects on subgroups of claimants, in particular, those that we have called administratively disadvantaged (…)’, who ‘(…) had a higher probability of leaving welfare for procedural reasons than for nonprocedural reasons’ (Reference Brodkin and Majmundar2010: 843). In other words, proceduralism can lead to non-take-up of services.
Brodkin and Majmundar further expect that these bureaucratic practices will be exacerbated when more (financial) pressure is put on these organizations. Such concerns are thus not limited to governmental bureaucracies distributing social security benefits but are also to be found in research on social service delivery by third sector organizations. For instance, research by Hanlon et al. (Reference Hanlon, Rosenberg and Clasby2007) shows that voluntary organizations in Canada cope with the pressures of government offloading and budget cuts by adjusting—rationing—the ways in which they offer and deliver their services. This may (further) decrease the visibility and accessibility of social service providers, which in turn may negatively affect take-up of social services that are offered by these organizations. And as for instance Henriksen et al. (Reference Henriksen, Smith and Zimmer2012) show, service levels may vary within countries and between countries (e.g. between the USA, Germany and Denmark).
Finally, at the individual level, impersonal treatment, creaming behaviour, and a passive attitude by representatives of third sector organizations may lead to non-take-up of social support. We derive this from the abundant literature that examines how street-level bureaucrats interact and cope with all sorts of citizen-clients (Tummers et al. Reference Tummers, Bekkers, Vink and Musheno2015; Maynard-Moody and Musheno Reference Maynard-Moody and Musheno2003; Lipsky Reference Lipsky1980). A potential structural source of conflict in such street-level interactions stems from ‘(…) the pressure for formal and impersonal treatment when individual, personalized consideration is desired by the client’ (Merton Reference Merton1940: 567). Representatives of third sector organizations may also display such behaviour, which can deter an individual in need of help, resulting in non-take-up.
Furthermore, to cope with their caseloads, they may become selective in choosing who they want to help, thereby preferring ‘easy’ or cooperative clients, which is also known as creaming or prioritizing (see Tummers et al. Reference Tummers, Bekkers, Vink and Musheno2015). These types of behaviour may occur when an individual first meets a service provider physically. However, not all individuals will become noticeable and actually come into contact with a representative of a third sector organization. If these representatives adopt a passive stance or a ‘wait-and-see-attitude’ (Sannen Reference Sannen2003), not all individuals in need of social support will be identified nor reached. In contrast to research of actual encounters between street-level bureaucrats and clients as described above, our understanding of this ‘pre-encounter phase’ in the help-seeking process is still limited. An important reason is that researchers face the challenge of finding this hard-to-reach, or even hidden population, a topic we will discuss more elaborately in our methods section.
Next to these factors on the ‘supply side’ that may negatively affect help-seeking behaviour, certain characteristics of individuals in need of help (the ‘demand side’) also need to be considered. In addition to examining the role and influence of knowledge and abilities, as identified by epidemiological research, public administration research investigates how bureaucratic competences impact helping behaviour. Bureaucratic competences refer to knowledge about the structuration and processes of the social welfare system and the abilities needed to cope with its complexities (e.g. Gordon Reference Gordon1975). Different studies report that some individuals cope better than others with the bureaucratic complexities of the welfare state (e.g. Hasenfeld Reference Hasenfeld1985). Although such studies shed light on encounters with governmental bureaucracies, there is only limited knowledge about the role of bureaucratic competences in the help-seeking process for social support from third sector organizations. Furthermore, as Sannen (Reference Sannen2003) mentions, negative personal views, attitudes, and beliefs regarding (potential) service providers may also lead to non-take-up of social support. Indeed, it is necessary to better understand the perceptions and ‘lived experiences’ (Wright Reference Wright2016) of individuals who are in need of social support. Many of the elements discussed here can also be linked to our previous discussion of socio-epidemiological and socio-cultural research.
Summarizing the Key Determinants of Non-take-up
In all, social-psychological, socio-epidemiological, socio-cultural and public administration research offers a wide range of potential factors that may cause non-take-up of social support. Table 1 summarizes the main determinants, including the studies and theories in which they appear most prominently:
Summary of the main determinants for non-take-up of social support
1. The desire to retain one’s (feeling of) independence and self-esteem (social-psychological research: reactance and threat to self-esteem models). If an individual feels threatened in his/her—often deeply felt—desire to remain independent and wants to maintain his/her self-esteem, he/she is more likely to be reluctant to ask for social support |
2. Socialization (socio-cultural research). Social conventions and cultural norms and values influence helping behaviour. How an individual is socialized may influence help-seeking behaviour |
3. Feeling rules (socio-cultural research). These pertain to the social conventions that ‘prescribe’ to individuals what they are supposed to feel in a specific situation, which steers (non)help-seeking behaviour |
4. Bureaucratic thresholds (public administration research). Non-take-up of social support may also be caused by a variety of bureaucratic factors, including impersonal treatment, waiting lists, complicated rules and procedures, and limited bureaucratic competences |
This theoretical summary is an important stepping stone towards improving our understanding of the phenomenon of non-take-up of social support and to further guide empirical research. In the next section, we elaborate on how our methods and data are informed by our theoretical framework.
Research Design
In this study, we adopt a qualitative approach to gain an understanding of the perceptions and ‘lived experiences’ (Wright Reference Wright2016) of individuals who are eligible for social support offered by service providers in the third sector, yet refrain from asking for that support. We employ two primary data collection methods: individual interviews and focus groups. A methodological challenge is that our target group constitutes a ‘hidden or hard-to-reach population’ (Shaghaghi et al. Reference Shaghaghi, Bhopal and Sheikh2011). That is, there is no register of individuals with (multiple) latent help needs from which to draw a representative sample, which is much unlike research on non-take-up of social security benefits that may draw from administrative databases of eligible welfare clients (see, e.g. Van Oorschot Reference van Oorschot and Andress1998). In addition, the recruitment of respondents who do not ask for social support is not a straightforward affair, as the unavailability of such registers complicates the process of reaching our target population. We therefore need to devise a suitable way of reaching individuals from this hard-to-reach target group.
To recruit respondents for the individual interviews we applied the technique of time-location (space) sampling (TLS): we mapped and visited different venues and establishments where individuals from hidden groups are expected to congregate (Shaghaghi et al. Reference Shaghaghi, Bhopal and Sheikh2011). For our sample population, potential respondents may be scattered over a wide array of locations. Hence, we identified different locations where individuals, perforce, come to satisfy (some of) their help needs, and aimed for variation across the ‘most likely’ but still accessible locations. The selected locations are the emergency room of a hospital, four food bank locations, and two locations of social work offices. Although these individuals receive at least some form of support at these locations, they may still have other unfulfilled help needs. Although accurate statistics for the city of The Hague are unavailable, a national-level survey, conducted by The Netherlands Institute for Social Research, estimates that around 8% of Dutch adults—living independently—are in need of more support than they actually receive (Verbeek-Oudijk et al. Reference Verbeek-Oudijk, Putman and de Klerk2017). Furthermore, we expect that respondents who are now receiving help are able to reflect on the time before they received it, when it was still difficult for them to ask for help (albeit there is the potential drawback of retrospective bias).
Interview Process and Data Analysis
We obtained proper authorization from the organizations involved to conduct our interviews at various locations in the city (one emergency room location, four food bank locations and two social work locations). Before starting, respondents were informed about the nature of the interview. They were assured that their responses would be used for research purposes only and that their participation had no consequences for any services or benefits they currently received or may receive in the future. Furthermore, anonymity was guaranteed: research output would not contain any detailed personal information and data would under no circumstance be shared with other parties. Finally, it was emphasized that there were no ‘right or wrong answers’ and that we were solely interested in their personal experiences with and perceptions of support from third sector organizations.
A total of 55 interviews were conducted, during each of which at least two interviewers were present: 20 interviews at the emergency room location, 24 at the food bank locations, and 11 at the social work offices. The duration of the interviews with our respondents varied between 30 and 45 min. Table 2 provides the basic descriptive statistics of our sample of individual respondents at the different locations.
Descriptive statistics of our sample of individual interviews
Food bank (n = 24) |
Emergency room (n = 20) |
Social work (n = 11) |
|
|---|---|---|---|
Female (%) |
46 |
70 |
64 |
Mean age (years) |
45 |
65 |
50 |
In addition to the individual interviews, two focus groups were organized. These served to further deepen our understanding of non-take-up (Morgan Reference Morgan1996) and as a means of data triangulation (Carter et al. Reference Carter, Bryant-Lukosius, DiCenso, Blythe and Neville2014). To recruit participants for the focus groups we tapped into the ‘knowledge of insiders’ and cooperated with a contact person, who is in relative proximity of the target group (cf. Groger et al. Reference Groger, Mayberry and Straker1999). In our case, participants were recruited in collaboration with the director of Stichting Kompassie. This is an independent, The Hague-based foundation that uses expert-by-experience volunteers, who provide free information and advice to individuals with (often multiple) personal welfare problems on where they can find social support. The director of the foundation acted as the ‘linking pin’ to recruit these expert-by-experience volunteers for our focus groups. There were eight experts-by-experience participating per focus group (total n = 16). Furthermore, each focus group was accompanied by a professional social worker, who was present the entire time to—if necessary—clarify questions (while not themselves actively participating in the focus groups). Both group conversations lasted well over an hour.
The main goal of the individual face-to-face interviews was to identify the reasons for non-take-up of social support. While we had prepared semi-structured interview questions based on the concepts derived from the literature, we made sure to leave sufficient room so that other reasons and conditions could emerge (Morgan Reference Morgan1996). We adopted a flexible, open-ended approach. The initial interview questions were about the respondents’ personal background and why they came to the location where they were interviewed. Depending on the direction the conversation was heading, more specific, in-depth questions were posed. Respondents were asked to reflect on the time before they received the help that they receive now, how they felt about it, and if it was difficult for them to ask for it (and if so: why). Furthermore, we tried to find out if respondents still had other help needs that were not (yet) fulfilled. If so, they were asked for the reason(s) why it proved difficult to ask for this support. Throughout the interview, the interviewees were asked to illustrate their experiences with concrete examples. Lastly, after the interviews, interviewees had the opportunity to bring up comments (if they had any).
With regard to social support, we distinguish amongst four types, according to their content: instrumental support, companionship, personal care, and emotional/psychological support (cf. Gottlieb and Bergen Reference Gottlieb and Bergen2010; Rook Reference Rook1987). When someone needs help with chores in and around the house, for example, this is categorized as instrumental support. Help wanted from a buddy, someone who meets with a person every now and then to go for a walk and have a chat, is coded as companionship. Personal care includes help with getting dressed, taking a shower, as well as light medical care. Finally, emotional or psychological support pertains to, inter alia, providing guidance, advice and/or coaching to address minor mental health needs. Table 3 provides some empirical examples to further illustrate these categories of social support.
Social support provisions from third sector organizations–empirical examples
Type of social support |
Social support from third sector organizations |
|---|---|
Instrumental |
Administrative help filling out tax forms with the help from a local community centre that offers financial support |
Companionship |
A bi-weekly social activity with a buddy from a local voluntary agency |
Personal care |
A social welfare organization offering home care after returning from hospital for revalidation |
Emotional/psychological |
An online platform of local residents offering support to individuals who suffer from emotional problems after losing their partner |
To enable empirical analysis of the interview data, a coding scheme was developed based on the relevant variables identified in the academic literature. Then, the first set of interviews was randomly selected and relevant quotes were filtered out and labelled. This process was continued until all interviews were handled. This provided us with a systematic overview of (1) the demographic data of our interviewees (age, gender, socio-cultural background, etc.), (2) the interview locations (enabling us to sort interview data by location), (3) the types of personal welfare problems, (4) the types of unfulfilled social support needs, (5) the reasons for non-take-up of social support, and (6) other relevant themes and issues that had emerged from the interview data inductively and were not directly related to the categories we had derived from the literature. In the following section, we report about our findings from the interviews and focus groups.
Empirical Findings
To provide a structured account of our empirical findings on the phenomenon of non-take-up of social support, we divide this section into three parts. In the first part, we present a general overview of the unfulfilled support needs, as derived from the individual interviews. Thereafter, we present the aggregate results on the determinants of non-take-up of social support, taken from the individual interviews. In the third part, we elaborate on and illustrate these findings with relevant examples both from the individual interviews and the focus groups.
Unfulfilled Support Needs
What types of social support do the interviewees state they need, but are reticent to request? In general, the types of personal welfare problems our respondents have are highly diverse, ranging from alcohol, debt and delinquency issues, psychological and emotional problems, to physical difficulties and discomforts. Their social support needs are quite diverse as well, but, as Table 4 shows, most individuals express a need for instrumental support.
Types of unfulfilled support needs identified in the interviews (aggregate results, n = 55, sorted by location). The total number exceeds 55, as some individuals express to have multiple support needs
Location type of social support |
Food bank (n = 24) |
Emergency room (n = 20) |
Social work (n = 11) |
Total (n = 55) |
|---|---|---|---|---|
Instrumental support |
||||
Administrative support |
17 |
2 |
3 |
22 |
Home care |
6 |
19 |
3 |
28 |
Companionship |
4 |
9 |
4 |
17 |
Personal care |
2 |
9 |
1 |
12 |
Emotional/psychological support |
5 |
3 |
3 |
11 |
Total |
34 |
42 |
14 |
90 |
Based on the interviews, we were able to further separate instrumental support into two subcategories: administrative support and home care. Administrative support includes help with household expenses, filling out tax forms, applying for social security benefits, and debt counselling. The other subcategory, home care, pertains to practical chores in and around the house (cleaning, repairs, etc.). The need for administrative support is most dominant—perhaps not surprisingly—amongst respondents at the food bank, while those at the emergency room, being relatively older, appear to be more in need of home care. The table further shows that the respondents often have multiple unfulfilled support needs at the same time, as the total number of needs (90) is substantially higher than the number of interviewees (55).
Determinants of Non-take-up of Social Support: Aggregate Results
What are the most important reasons why our respondents do not ask for social support services from third sector organizations? Table 5 presents the aggregate results from coding all individual interviewees’ narratives (n = 55). Bureaucratic barriers are most frequently mentioned as a reason for non-take-up of social support (n = 24), closely followed by the desire to remain independent (n = 22). Other determinants for non-take-up, socialization (n = 11) and feeling rules (n = 13), appear to play a less prominent role in our study. Note that sometimes multiple reasons play a role simultaneously—which is why the total number adds up to 70.
Reasons for non-take-up of social support from the individual interviews (aggregate results, n = 55, sorted by location). The total number exceeds 55, as some individuals provide more than one reason
Location determinants |
Food bank (n = 24) |
Emergency room (n = 20) |
Social work (n = 11) |
Total (n = 55) |
|---|---|---|---|---|
Bureaucratic barriers |
11 |
8 |
5 |
24 |
Retaining independence |
9 |
10 |
3 |
22 |
Feeling rules |
7 |
3 |
3 |
13 |
Socialization |
4 |
5 |
2 |
11 |
Total |
31 |
26 |
13 |
70 |
Based on this brief overview of the (most important) reasons for non-take-up, we now proceed to illustrate these findings with relevant material that we gathered from the individual interviews and focus group conversations. The aim is to gain a more in-depth understanding of our respondents’ personal perceptions and ‘lived experiences’ (Wright Reference Wright2016) and why they do not ask for social support, despite their eligibility for such services.
Determinants of Non-take-up of Social Support: Empirical Illustrations
For the remainder of this section, we follow the results in Table 5 in order of their relevance. This means that we will first elaborate on the (perceived) bureaucratic barriers, then we turn to illustrate how (the feeling of) retaining independence leads to non-take-up, and finally we present some examples of socialization and feeling rules.
Bureaucratic Barriers
In general, bureaucratic factors are mentioned most frequently (n = 24) by our interviewees as obstacles to social support services. As described in our multi-level model (Fig. 1), bureaucratic barriers can manifest themselves at the system level, the organizational level, and the individual level. According to our data, most pronounced are the bureaucratic problems and obstacles at the organizational level. Complicated bureaucratic rules and procedures, inadequate information provided by organizations about (the availability of and eligibility for) specific support provisions, language issues, but also negative (previous) experiences with (other) third sector organizations, are oft-cited obstacles to effective utilization of social support. As a result of such organizational barriers, many respondents did not manage to find suitable support for all of their—sometimes pressing—help needs. One of our interviewees, a single mother (age 32) with four children who, at the time, had no kin or other close relations nearby, was in need of administrative support. However, she did not utilize the free social services provided by an agency in her neighbourhood, as she was unaware of their existence. An unemployed single man (age 54) with children experienced a lack of information about support services from third sector organizations: ‘Information about services from such organisations is just less visible to me’. And others, such as two male interviewees (one aged 30, originally from Armenia; the other originally from Turkey, age 65), did not know how and where to apply for support due to a language barrier (information was only available in Dutch and English, not in other languages).
Quite a number of respondents felt demotivated, sometimes even depressed, due to the ‘bureaucratic hassle’ they encountered. A woman (age 33), who was in need of emotional support, explained that initially it took some time to overcome her hesitation to ask for help. Once she did, she visited various organizations to seek support, but she ended up not receiving any help. She said, sighing, ‘Instead, I was being sent from pillar to post, which did not make me feel any better, as you can imagine’. Others had similar experiences. A single man (age 43), suffering from mental health problems, complained about the lack of a central information office to assist individuals in finding the right provider for social support, which could prevent them from being directed from one agency to the next. A married woman (age 54), who was in need of debt counselling, found it exhausting and aggravating when she had to explain her situation over and over again.
In addition, while acknowledging her personal responsibility in having debt problems, she felt she was ‘being treated as a number instead of a person’ and felt ‘reduced to yet another person with money problems’. Participants in the focus groups argue that such practices often inhibit individuals from talking about their social support needs. As a result, (some) help needs remain hidden and are never properly addressed. Based on personal experiences as well as their observations in their consulting practice, the experts-by-experience often see that individuals seek advice about, for instance, administrative support, and that underlying problems (e.g. illiteracy, mental health problems, addiction) come to the surface only when they feel safe enough and get an opportunity to talk more broadly about their lives. As stated in one focus group, ‘Then someone opens up and the cracks become visible. Then you can do something about it. Together you can figure out how to deal with it’.
At the individual level, respondents regularly indicated that professionals, such as general practitioners or social workers, played a crucial role to access third sector organizations. Many respondents did not know about being eligible for, e.g. food bank or voluntary home care services, until they were made explicitly aware of their social rights by these professionals. In the focus groups, it was added that confusion often arises as a result of the difficult language used by representatives of third sector organizations: ‘It is that bureaucratic language which is difficult to comprehend’. And if individuals do arrive at the organization’s door, their problems are usually only partially addressed, leaving aside other help needs and underlying problems, according to the focus groups.
Moreover, both from some individual interviews and from the focus groups, we observed a spill-over effect. This means that a negative experience with representatives one particular (governmental or third sector) organization can have an impact on an individual’s willingness to seek help from other—oftentimes entirely unrelated—organizations. Participants in one focus group stated individuals ‘(…) fear contacting the tax administration office (…) some are afraid of government (…) intimidated by complicated bureaucratic language (…)’.A conflict about a tax return, a dispute about a permit for renovating one’s house, or comparable experiences can ‘spill-over’ and negatively affect help-seeking behaviour for social services from (other) third sector organizations.
Finally, at the system level, we observe that fragmentation of service supply, lack of information, general system complexity, and social policy reforms pose important obstacles to effectively seeking suitable sources of support. For example, with regard to the information on a municipal website containing information on all sorts of social services. Or, as one focus group participant said: ‘The computer itself is also a threshold. Even I cannot find information on that website. And I can definitely imagine that someone with a disability says: “I just don’t get it”’. In general, both focus groups corroborated that it is difficult to navigate the fragmented and complex system of social support services. Many individuals in need of social support are unaware of the existing supply of services and their eligibility for (free) social services offered by third sector organizations.
Social policy reforms can also have a detrimental impact on help-seeking for social support. A number of individuals that we interviewed indicated that they had difficulties to cope with reforms of help arrangements, especially when existing help—often a trusted relationship—was being altered or even aborted due to budget cuts or other types of policy reforms. Such changes affected the attitude towards help-seeking of some of our interviewees in various ways. One man (age 35), who had been addicted in the past and was still dealing with emotional problems, complained about this. He used to receive help from a trusted volunteer of a local community centre, but this had ended abruptly after the centre was shutdown due to budget cuts. This was a huge disappointment and setback, which resulted in the man becoming reluctant to search for new social support. More respondents explained that it is very difficult to build a new relationship with new support providers. Some even stopped trying and ‘accepted’ that they would not receive help anymore. Others had lost all hope of receiving help after having had negative encounters in the past. One interviewee, a single, unemployed male (age 43), who no longer received home care, does not ask for help anymore, ‘because by now I know that I will not get help anyway’. In some cases, negative experiences even led to resistance towards seeking new or alternative sources of help.
Retaining Independence
The second most important determinant for non-take-up that we derived from our data is the desire to retain one’s (feeling of) independence and self-esteem (n = 22). One illustration is that of a widow (age 75) who wanted to remain independent for as long as possible. She also continued to care for her mother-in-law by herself after her husband had committed suicide, until she reached a point at which she could no longer cope with it physically. Only then did she start looking for help. Another example is of an unemployed man (age 47) who got into serious debt problems. He and his wife hesitated for a long time before asking for help: ‘That feels really lousy. It’s not what you want, but it was our last resort. We’re not like “Can you please help me?”, especially when you are used to your independence for 20 years. Asking for help is just not our thing.’ Others, whose help needs had not (yet) become as pressing, also expressed how much they valued their independence. As one woman (age 72) responded to the question as to why it was difficult for her to ask for help: ‘I’m used to doing things myself. That’s who I am.’ Another woman (age 45), who indicated that she would benefit from several different forms of support (administrative, emotional, home care), yet did not ask for it, as she wants to be self-reliant. She further added: ‘You just have to say to yourself: it will pass by, tomorrow it will get better’.
Furthermore, a substantial number of respondents indicated that their situation had become quite hopeless before they finally took the step of asking for (at least some) help. This was especially the case with individuals who wanted to hold on to their (feeling of) independence as much as possible. For example, a divorced man (age 57) decided to go to the food bank only after his (debt) problems became insurmountable. He did not want to become (financially) dependent upon others and it took him a very long time to take action. Due to his divorce and debt issues he had lost many friends. Still now, also after receiving some help from the food bank, he is hesitant to ask for additional social support—even though he indicates that he could use some extra help.
Socialization and Feeling Rules
As our aggregate results in Table 5 indicate, we find some evidence for socialization (n = 11) and feeling rules (n = 13), but overall these determinants appear to play a less dominant role in the non-take-up of social support. Nonetheless, we round off this section of empirical findings with illustrations of how socialization and feeling rules can lead to non-take-up of (some forms of) social support. Regarding socialization, some respondents explicitly referred to how cultural norms and values influence their help-seeking behaviour. For example, a married woman (age 40) explains that in her culture—she and her family are of Turkish origin—it is not customary to ask for help outside of the family, even though she indicated having various support needs. A single woman with children (age 51), a first-generation immigrant from the former Dutch Antilles, expresses a similar view. In her personal experience, asking for help is ‘very difficult in my culture’, so she is reluctant to do so.
Another female respondent (Moroccan origin, married, age 39) says she does not ask for help outside her family, even though she sometimes suffers from back problems and bears most of the caring responsibility for her five children as well as for her mother. She says: ‘When I feel lost, I turn to my husband. He understands me and he reassures me. He tells me how proud he is. This is how we are used to helping each other in difficult times’. In both examples, some form of family obligation (cf. Guo et al. Reference Guo, Nguyen, Weiss, Ngo and Lau2015) appears to be the reason not to ask for social support from third sector organizations. In addition, a number of respondents—including some of Dutch origin—told us that it was ‘just the way they had been raised’, which made it difficult for them to (start) ask(ing) for help. They said they simply did not know any better and tried to manage on their own.
Lastly, we provide some illustrations of why and how feeling rules inhibit help-seeking from third sector organizations. Several interviewees mentioned that they refrain from asking for help because they believe it ‘violates’ a general social norm. One focus group participant stated that it is ‘not done’ for highly educated people to ask for help, as they are considered to be able to take care of themselves. Furthermore, our data seem to corroborate other studies that feeling rules come into play in situations when help needs become more intimate (cf. Vreugdenhil Reference Vreugdenhil2012; Linders Reference Linders2010). For example, a single Dutch woman (age 59), who receives support from a ‘buddy’ (companionship) does not want to talk with her buddy about her alcohol addiction and underlying psychological problems. She considers it inappropriate to, in her own words, burden her buddy with it. And a single man (age 85), who receives instrumental support (cleaning the house) from a home care organization, does not want to ask for additional help with preparing his meals since he feels one should be able to prepare one’s own meal. Only if it is really necessary he would ask his daughter or neighbours to help him out. So, in these cases, individuals already receive some form of support from third sector organizations but refrain from asking for additional help for other help needs that they consider to be more personal or intimate.
Although feeling rules are in a way related to socialization and cultural factors (see Hochschild Reference Hochschild1979), there seem to be at least two important differences between the two types of determinants. Based on our data, it seems that (1) feeling rules stem from general social norms that individuals ‘translate’ into social guidelines for specific help-seeking situations, while socialization is more about the particular norms and values one has received in one’s upbringing; and (2) the role and impact of feeling rules on help-seeking varies according to the ‘level of intimacy’ of help needs, while socialization affects all help-seeking behaviour, regardless of the type of help needed. These are tentative findings, however, and more research is required to see how feeling rules ‘work’ and how they relate to (cultural) socialization specifically.
Discussion and Conclusion
To curb welfare costs, policymakers increasingly expect individuals to utilize social support provisions from third sector organizations, as a complement to, or sometimes as a substitute for publicly funded support. However, assuming that sufficient help is available from such organizations, it is not always self-evident that individuals will effectively utilize these resources. Not much is known about the causes of this non-take-up of social support. Our study makes an important contribution to better understand this complex phenomenon by drawing together relevant insights from different—and up until now largely separated—academic disciplines. Our empirical results provide indication that (perceived) bureaucratic obstacles and the desire to maintain one’s (feeling of) independence are two critical barriers in the help-seeking process. Below, we discuss our study’s implications for academic research; evaluate its limitations; formulate future research avenues; and draw some lessons for (policy) practice.
Implications for the Academic Debate
Our study has several implications for the academic debate. Perhaps most importantly, it is necessary to move towards a more integrative approach to study the phenomenon of non-take-up of social support. While different academic disciplines have unquestionably yielded relevant knowledge and insights on help-seeking behaviour in a range of contexts (e.g. help-seeking for professional medical care), this knowledge is rarely directly related to the particular phenomenon of non-take-up of social support. In addition, these academic disciplines have focused on different aspects of help-seeking behaviour and have done so in relative isolation from one another. Social-psychological research focuses on help-seeking at the individual level, while socio-epidemiological and socio-cultural research explicitly incorporate the broader social and cultural context. Public administration research is of added value to understand the impact of bureaucratic rules and procedures on non-take-up of social support but has paid only scant attention to the role of psychological factors. Moreover, while public administration research has produced a vast literature on ‘bureaucratic encounters’ (Kahn et al. Reference Kahn, Katz and Gutek1976) between clients and public bureaucracies, the ‘pre-encounter phase’ has received only scarce attention.
Overall, our study suggests that the causes of non-take-up of social support are neither confined merely to ‘external’ bureaucratic barriers nor are they limited to factors at the individual level. Instead, it seems that non-take-up of social support is caused by an intricate interplay of different factors that operate at different levels—ranging from the ‘internal, personal level’ to the ‘interpersonal, social level’ and the ‘broader, organizational/system level’—throughout different phases of the help-seeking process.
Limitations of this Study and Avenues for Future Research
Although we consider our qualitative study as an important first step, it does not provide an exhaustive account of non-take-up of social support and is of an exploratory nature. There are several limitations. Firstly, the generalizability of our findings is limited because of the relatively small sample size and the limited range of locations. So, extending this research to other locations in other Dutch municipalities and in other countries would further strengthen the external validity of the current findings. Additionally, such a large-N research design would allow for testing whether there are significant relations between locations, types of need, and reasons for non-take-up. It would be interesting to investigate if there is a relation between the type of services needed and the experienced barrier. One can, for example, hypothesize that when emotional support or personal care is provided, the (perceived) loss of personal freedom could be a more important barrier than if a person only requires practical support (cf. Mazelis Reference Mazelis2017).
At the same time, a methodological challenge—endemic to this type of research—is the unknown size of the total population of individuals with (multiple) ‘hidden’ help needs, as well as the unavailability of registers of individuals with latent help needs (which are more readily available in research on social security benefits, for instance). This severely complicates the process of recruiting large numbers of respondents from the target population. From a methodological point of view, this implies that researchers should pay special attention to sampling strategies. Nonetheless, despite the limited statistical generalizability, we do provide a basis for future research in terms of ‘analytical generalizability’ (see Yin Reference Yin2013). Finally, to a large degree, we were dependent on what our respondents told us in the interviews. Although the focus groups functioned as an important source of data triangulation, due to (obvious) ethical and privacy considerations we could not consult personal files to ‘check’ statements about individual situations. Yet we see no reason to doubt the answers that our respondents provided, as confidentiality and anonymity was guaranteed and the research did not have any consequences for their social rights.
Our finding that some of our respondents show ‘resistance behaviour’, while actually being in need of social support, provides an interesting lead for future research. This corroborates other studies reporting that there is a real risk of exacerbating non-take-up when individuals lose existing help due to budget cuts or other types of policy reforms and feel ‘forced’ to find substitute help (Grootegoed and Van Dijk Reference Grootegoed and Van Dijk2012). Consequently, some even start to resist to ask for substitute help, while they actually are in need of receiving help. So while non-take-up of social support may occur in situations of policy stability, it is likely to be aggravated under circumstances of policy turbulence. Additional research is needed to investigate this specific type of behaviour under such circumstances more thoroughly.
Another avenue for future research is to investigate help-seeking behaviour for social support within an individual’s private social network. Here we focused on individual helping behaviour in the context of third sector organizations. However, policymakers in many countries also identify an individual’s social network as an important source for support (see, e.g. Van der Voet et al. Reference van der Voet, Steijn and Kuipers2017). Whereas a number of determinants identified in this study (feeling of independence and self-esteem, socialization, feeling rules—and perhaps also norms of reciprocity, as identified by equity theory) are likely to play a role, future empirical research should investigate help-seeking for social support in that particular context as well.
A third way forward for future research is to adopt a longitudinal research design, so as to follow individuals and study variance in help-seeking over time. This would allow us to investigate why and how some individuals display ‘temporary non-take-up’ (Van Oorschot Reference van Oorschot and Andress1998), while others display more permanent forms of non-take-up behaviour. Such a design also allows for monitoring individual behaviour after their (negative, positive, or neutral) encounters with third sector organizations. Differently put: how do such ‘lived experiences’ (Wright Reference Wright2016) affect future help-seeking for social support from third sector organizations? And, finally, follow-up research should also consider to include the perspective of third sector organizations next to that of potential service recipients. Whereas this was outside the scope of the current paper, it would be interesting to investigate how these organizations perceive the phenomenon of non-take-up of social support and how they try to cope with it.
Lessons for Practice
Our research also bears several lessons for practice. A central, yet often implicit assumption in social policies seems to be that all citizens are equally confident, rational, self-conscious, active, and competent (Wright Reference Wright2016; Van Oorschot Reference van Oorschot and Andress1998) and are thus equally (cap)able to organize their own social support. But in practice, there is variation in the degree to which citizens can manage this. For a variety of reasons, it can be quite daunting for individuals to effectively navigate the complex, often opaque world of third sector organizations to ask for the support that they need. Therefore, as Wright accurately argues, ‘it is crucially important that policy makers begin to engage with evidence verified by authentic accounts of lived experiences; of the meanings and impacts of a range of welfare conditionality measures; the complexities of motivation; and the relationships between intentions, actions and outcomes’ (Reference Wright2016: p. 250). What our study hints at is that to improve service delivery through reducing non-take-up of services, policymakers should be (more) attentive to bureaucratic obstacles at the organizational level, instead of (only) trying to change individual help-seeking behaviour.
Secondly, our findings seem to warrant a plea to add more generalist social workers and/or organizations to better guide individuals who are in need of support and to better cater to their—often complex—personal welfare problems. Several scholars emphasize the importance of striking the right balance between specialized and generalist services (see, e.g. Raeymaeckers Reference Raeymaeckers2016; Blom Reference Blom2004). And as Raeymaeckers (Reference Raeymaeckers2016) finds, generalists act both as brokers and as mediators. They ‘can facilitate interactions between clients and specialist service organisations’ (Reference Raeymaeckers2016: p. 624). Although additional research is needed, based on the indications from our study it is likely that many individuals who are in need of social support could benefit from such generalists and a more generalist approach.
To conclude, this study shows that non-take-up of social support is a multi-dimensional phenomenon. We argue that it should be studied from a perspective that incorporates insights from social-psychological, socio-epidemiological, socio-cultural, and public administration research. Hopefully, this forms the starting point of a fruitful dialogue and exchange amongst different academic disciplines in the pursuit of better understanding non-take-up of social support.
Acknowledgements
We kindly thank all participants in this study for their valuable contributions. We also would like to thank Liselotte Hagen and Theanne van Schaik for their excellent assistance with the interviews. Finally, we thank the two anonymous reviewers for their valuable comments and suggestions on the previous version of this article.
Compliance with Ethical Standards
Conflict of interest
The authors declare that they have no conflict of interest.
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