Mental illness remains as one of the most stigmatizing conditions in contemporary western societies. This study sheds light on how mental health professionals and rehabilitants perceive stigmatization. The qualitative study is based on stimulated focus group interviews conducted in five Finnish mental health rehabilitation centers that follow the Clubhouse model. The findings were analyzed through inductive content analysis. Both the mental health rehabilitants and the professionals perceived stigmatization as a phenomenon that concerns the majority of rehabilitants. However, whereas the professionals viewed stigma as something that is inflicted upon the mentally ill from the outside, the rehabilitants perceived stigma as something that the mentally ill themselves can influence by advancing their own confidence, shame management, and recovery. Improvements in treatment, along with media coverage, were seen as the factors that reduce stigmatization, but the same conceptualization did not hold for serious mental illnesses. As the average Clubhouse client was thought to be a person with serious mental illness, the rehabilitation context designed to normalize attitudes toward mental health problems was paradoxically perceived to enforce the concept of inevitable stigma. Therefore, it is important for professionals in rehabilitation communities to be reflexively aware of these tensions when supporting the rehabilitants. The people living today belong to the same species, but their various group memberships are a constant source of inequality, prejudice, injustice, and discrimination. Certain ethnic groups may be perceived negatively in the moral and ethical domains, working-class people in the domain of intelligence and competence, women in the technical and mathematical domain, and so on. Some groups, such as those who are mentally ill, suffer from a more severe global devaluation. Such devaluation encompasses not only individual experience but is also part of a wider scope of societal development, historical contingencies, power relations, community practices, and policies.Stigma is the central notion pertaining to people’s tendency to devaluate others. It is a concept that refers to “a mark of shame or discredit” (Merriam-Webster Dictionary) that leads others to disapprove of or hold negative beliefs about certain individuals, qualities, or circumstances. The most influential theoretician of the 20th century to provide a theory of stigma was Erving Goffman 1963). Goffman’s stigma theory draws on the notion of stigma as a process, whereby the reactions of others spoil normal identity. In this process, a person with an attribute that is discredited by their society is rejected because of this attribute [963. GoffIn this paper, we discuss how mental health rehabilitants and the professionals working with them perceive the devaluations, such as stigma, that are associated with mental illness. First, we will provide an overview of the literature, focusing on how stigma is manifested in mental illnesses.The stigmatization of people with mental illness demonstrates a millennia-long history of social exclusion and prejudice, connecting mental disorders to the belief in the Middle Ages that they are a punishment from God and to genocide during the Nazi reign in Germany . As poinStigma affects persons with mental illness in multiple ways . They arThere is a substantial body of research on how stigma impedes mental health rehabilitation. In a seminal paper from 2004, Corrigan outlines how stigma both decreases the self-esteem of people with mental health problems and robs these people of social opportunities, in this manner impeding these people from seeking mental health services ,29. AparStigma does not affect only people with mental health problems, but also health care professionals. For example, previous research has identified the phenomenon of diagnostic overshadowing, which refers to the process in which physical symptoms are misattributed to mental illness. This phenomenon is assumed to relate to premature mortality in people with mental illness see, e.g., . There iWhen it comes to mental health professionals, one would expect that their attitudes toward people with mental illness would be better compared to the general population since their profession involves dealing with mental illness as a normal part of life. However, previous research has demonstrated that even mental health professionals may hold negative beliefs about individuals with mental illness and contribute to their discrimination. For example, a survey conducted by Nordt, Rössler, and Lauber  showed tIn this paper, our aim is to shed light on some inherent tensions and paradoxes of stigma in the context of community-based mental health rehabilitation. We investigate the following: (1) How mental health rehabilitants and professionals perceive, explain, and account for mental illness stigma; (2) How the participants’ stigma talk is associated with their institutional positions as professionals or service users.We assume that the answers to these questions will increase the overall understanding of stigma in contemporary mental health rehabilitation, ultimately helping us unveil the possible tensions in the views of mental health rehabilitants and professionals.Our data consist of 10 video-recorded focus group interviews that were organized in five Finnish Clubhouses. The Clubhouse model is a worldwide concept involving local community centers that offer people with mental illnesses a sense of belonging, opportunities for social relationships, and support in obtaining employment, education, and housing . A ClubhThe Clubhouse units were chosen to be included in the study through a purposive sampling designed to provide maximum variation. The chosen units varied in age, geographical location, and number of members. The interview tour continued until the saturation point was reached. Two groups in each house were interviewed: one group consisted of clients and the other comprised support workers. To promote inclusion, participants were recruited through an open call and not selected based on any particular criteria. All voluntary participants were accepted. There were between three and seven participants in each group, as well as one interviewer, who conducted all of the interviews. All of the participants were adults who had been involved in a Clubhouse community from 1 to 21 years.The structure was similar in each interview, but the groups were encouraged to continue the discussion freely around each question . TheFocus groups are suitable for studying comprehension on known issues, such as stigma related to mental health issues, cf., . The metIn this paper, we examined the stimulated discussions on the stigma related to mental health problems. As stimulation, the groups were given three cards with percentages printed on them: 47%, 62%, and 71%. They were told that one of the answers depicted the percentage of mental health rehabilitants that experience stigmatization because of their mental illness in Finland, according to the Finnish Mental Health Barometer . For theThe interviewer introduces the topic and the cards.The group contemplates which card to choose.The group justifies their choice.The interviewer reveals the result of the national barometer.Broad discussion.The interviewer shifts the topic.In the interview, the groups were asked to work together and choose the card they thought correctly depicted the prevalence and to provide explanations for their choice. After their decision, the interviewer revealed the result of the barometer (47%) and asked the group to deliberate. Thus, the stimulated group discussion consisted of the following stages:The interviewer’s task was to encourage the groups to think aloud and discuss the theme broadly. If the groups’ own evaluation differed from the barometer’s result, the groups were asked to contemplate the reasons for the divergence. Before the interview, the groups were also encouraged to provide examples and anecdotes whenever they found fitting. The interviewer refrained from leading the group to any conclusions and moved on to the next stage only after the discussion seemed to cease or drift too far from the topic.The interviews were transcribed for the study and analyzed using the qualitative method of inductive content analysis . The conThe study was conducted in accordance to the Declaration of Helsinki and the project acquired a statement of validity from the Ethical Review Board in the Humanities and Social and Behavioural Sciences in the University of Helsinki . All participants were given written and oral information about the study and the data management, and each participant signed a written consent. As the identities of the participants are confidential, all personal data were omitted or changed during the transcription process. In addition to the recorded interviews, no other information was collected from the participants. In the extracts, the participants were identified with pseudonyms.Our results show how the mental health professionals and rehabilitants evaluated and rationalized the prevalence of stigma  and how In the stimulation task, in which the groups were asked to evaluate the prevalence of experiences of stigmatization among mental health rehabilitants, none of the groups chose the card that depicted the percentage presented in the Finnish mental health barometer, namely, 47% . InsteadThe participants’ common explanations for their decision in the stimulation task are illustrated in By depicting the prevalence as still strong, the participants indicate that stigma has also existed in the past (Extracts 1–3). The underlying idea seems to be that there have been efforts to diminish stigma, but they have not made a notable difference (Ext. 4). The participants’ notions of the past seem to refer to the historical burden related to the treatment of the mentally ill in western societies, cf. , but theAnja, support worker: “I think it is still like this” (points at 71%).Seija, support worker: “It’s a high rate anyway. Could it still be at 71%?”Jonna, client: “Stigma is (--) still extremely strong.”Oiva, client: “The situation with stigmatization has not improved much.”The support workers also appealed to having often heard about incidents of discrimination. They explained that the clients often discuss experiences of stigmatization at the Clubhouse. What is noteworthy is that the support workers in different houses produced very similar narratives of mental health rehabilitants not being heard in primary care consultations because of their diagnosis (Ext. 5–7).5.Anja, support worker: “One can be Otherwise ill or in pain, but it is always automatically linked to… Oh you have these psychological issues so these are probably just symptoms of that then.”6.Ulla, support worker: “Yeah, and if you go see a doctor or something and you have an entry, whether it is about mental health, addiction or anything, you will definitely be treated differently.”7.Maikki, support worker: “I’m thinking of the people who have a physical condition. When they go see someone in primary care, like, what does it take for them to be heard? Like, when you think they have a mental health problem.”In the foregoing, we have mentioned how diagnostic overshadowing can increase the risk of health complications for people with mental illness, see also . As demoThe clients, on the other hand, appealed to their own first-hand experiences rather than others’ reports. Some confessed that they had lost friends and other social contacts due to their illness. However, incidents of diagnostic overshadowing were not mentioned, which suggests that from the clients’ perspective, the attitudes of their close contacts are central with regard to their experience of belonging. Some groups also talked about misconceptions they have encountered, such as the belief that mental illnesses are a matter of attitude and not actual illnesses (Ext. 8).8.Mari, client: “Older people, in particular, think that mental health problems are not health problems.”Mikko, client: “Self-inflicted.”Mari: “We could get rid of them just by deciding (*laughs*) not to be bipolar or whatnot anymore.”The clients were also aware of self-stigmatization and its effect on how they perceive other people’s attitudes towards themselves Ext. 9–11) ,11,12,13 ,11,12,19.Milla, client: “When you become ill, the shame is a heavy burden. One thinks, I am so shameful that everyone else will condemn me as well.”10.Saku, client: “It is a very personal experience. Do you feel like you are being labeled? Do you see yourself as different in some way?”11.Mari, client: “I possibly see it that way. That many people experience stigmatization although others do not stigmatize them that much.”The clients also agreed that acknowledging one’s own problems and their consequences is key to accepting one’s self and conquering the shame (Ext. 12). This notion is in line with previous studies. For example, being comfortable with using mental health services correlates with having fewer discriminating beliefs about mental illnesses , whereas12.Netta, client: “When one gets back on one’s feet, one sort of recovers. Like, I have this thing but maybe it’s okay. It then decreases, and one starts to think that it isn’t that terrible to have something.”What is interesting is that the trained support workers viewed stigmatization as something that is forced on the mentally ill, whereas the clients’ discussions left more room for the rehabilitants’ own agency. That is, having confidence in one’s self can reduce the experiences of stigma. We will investigate the viewpoints of the clients and the professionals further in the next section, in which we analyze how the participants received the result of the national barometer.After the results of the national barometer were revealed, all of the 10 groups were positively surprised. When asked to contemplate the reasons for the divergence, the groups gave explanations that relied either on underestimating the effects of societal changes  or on haIn each group, there were participants who, after having heard the barometer result, reasoned that the situation with stigma must have improved significantly of late. However, the percentage of mental health rehabilitants that experience stigmatization because of their mental illness had in fact increased from the previous barometer results  . A close13.Venla, client: “There is a historical burden when you consider how the treatment has been. People were locked up in big institutions far from the city centers. The young have been born in a wholly different world.”14.Jutta, client: “The hospitalization, as well, because I think that in the past, once you ended up in a mental hospital, you did not get out again.”15.Jonna, client: “Could that have something to do with outpatient care being in (--) such good shape these days?”16.Janette, support worker: “Medication has changed a lot during the time we have worked here. Like, one can actually see that people’s symptoms have changed and diminished, or that the drugs are more effective.”The changes in diagnostic terminology were also perceived to increase acceptance of mental health rehabilitants. For example, changing “manic-depressive disorder” to “bipolar disorder” and “minimal brain dysfunction” to “ADHD” were mentioned as improvements that have reduced stigma. Another factor seen as separating the current times from the past in a positive way was publicity. Media attention and celebrities coming out with their mental health problems were seen as aspects that reduced stigma .17.Netta, client: “Many celebrities have come out with having such problems, so ordinary people now also dare to become more public about it. Like, it isn’t a bad thing anymore but a strength.”18.Janette, support worker: “This is wonderful news, and I think it could be due to the good work the celebrities have done here. Almost daily, one sees headlines and front pages that focus on mental health problems.”Prior research by Ferrari  has indeBeing open about mental health problems was regarded to be considerably easier for young people, as they have been accustomed to talking about mental health and have received information about it from an earlier age compared with previous generations . The participants thought it was easier for young people to talk about mental health with their peers and in public. Discussing and taking care of one’s health and wellbeing in general was seen as belonging to a culture accepted and maintained by the young . These examples show that the proactive denial strategies , which a19.Riina, client: “I told my grandma it is my illness. I tell whomever I want about it, but maybe it is because I am younger and I have grown into it and we have been taught about mental health.”20.Tuula, client: “Maybe younger people understand these things better.”21.Ida, support worker: “There is an age-related cultural difference. (--) it is in fashion, in quotation marks, to take care of one’s head. (--) overall, caring for mental health, in my opinion, is less of a taboo for young people.”In two groups, some of the support workers connected the openness about mental health problems to a change in work ethics. They seem to suggest that talking about mental health problems and taking sick leave because of them are signs of a weak work ethic, although they represent these concepts as generalizations rather than their own personal views . Again, the young are regarded as different from the others; they pay attention to their mental health and risk being labeled as unreliable workers. There is indeed evidence of burnout sufferers struggling to legitimize being sick in a work-centered society such as Finland, because sick leave is often related to exploiting the welfare system . The sup22.Marko, support worker: “The older generation has strong work ethics, and this idea of sort of giving up psychologically does not fit in it. But, I mean, for a young person, it may be acceptable to admit that one does not manage or care.”23.Support workers:Varpu: “I don’t know ANYONE my age who would have talked about having depression when we were young.”Maikki: “Nor do I.”Varpu: “Whereas nowadays it is completely.“Seija: “No. Back then people would go to work, and work until the end. For real, you definitely would not have taken a sick leave because of depression.”However, other groups found a strong connection between changes in working life and the increase in mental health problems . They discussed how work has become more demanding, stressing, and fragmentary. Burnout was seen as a result of working life getting hard, not a change in work ethics among the young. One of the clients also proposed that the changes in working life explain why older people do not understand the young (Ext. 26).24.Anja, support worker: “Many have gotten sick because of work.”25.Venla, client: “They are so common, burnouts and everything. It can be so tough these days. I mean, like, you have to be in a very good condition to manage in the working life. It is a hard game nowadays.”26.Kyösti, client: “Therefore, the older people don’t understand the younger ones because the working life has been so different.”Nearly all of the groups reasoned that stigma may have diminished due to mental health diagnoses becoming more common. The idea behind this is that being familiar with mental illness decreases prejudice , and tha27.Jutta, client: “In Finland, it’s one in five, I suppose .”28.Venla, client: “It really is a lot if nine people retire every day because of depression.”29.Kale, client: “Nowadays, nobody stigmatizes anyone for anything because everyone is just as nuts there on the streets. Everyone should probably have some sort of a diagnosis but just haven’t been examined. (--). Forty years ago, only a couple of percent had ADHD, but now, pretty much the whole nation of Finland has it.”30.Clients:Kyösti: “If you are overly well-mannered, that too is classified as being crazy these days.One shouldn’t be (--).”Kale: “It is abnormal.”Mari: “A good actor is a psychopath.”Overall, all of the groups jointly and unanimously constructed a narrative of stigmatization diminishing over time, although they had underlined the persistence of stigma just a moment before in the evaluation task. Hence, the idea of having overestimated the prevalence seems to function as evidence of improvement. What is noteworthy is that despite discussing working life becoming harder and mental health problems, sick leave, and disability pensions becoming more and more common, none of the groups saw a possibility of negative development through which stigmatization would get stronger. The current issues were instead understood as attenuating factors that promote acknowledgement and inclusion.The only departure from the narrative of progress with regard to stigmatization concerns the status of mental illnesses that the groups considered as serious conditions. Some participants claimed that the attitudes have improved only toward those whose conditions have recently become regarded as “fashionable”. Depression, burnout, ADHD, and bipolar disorder were named as popular conditions, whereas schizophrenia was regarded as unfavorable with respect to media appeal (Ext. 31).31.Support workers:Taru: “It isn’t as media-sexy to feature a women’s magazine narrating a story about having paranoid schizophrenia. It is completely different from getting burnout.”Oona: “Burnout sounds like you are a hero and a victim. You have languished under a burden.”Previous research has proven that social distance toward people with schizophrenia is larger than toward those with depression due to the anticipation of social disability . People When the groups were asked to contemplate the reasons for the divergence between their views and the barometer’s result, in addition to considering having underestimated how much society has changed, the groups underlined their own experiences and knowledge of the matter. A common interpretation was that mental health rehabilitation is an environment that enhances the awareness of stigma. Rehabilitation was perceived both as a context that supports a comprehensive understanding of stigma and as a context that distorts the perception. We will specify these views in the following.Right from the first stage of the stimulation task, the client groups justified their high estimation of the prevalence of stigma with their first-hand experiences of prejudice and shame see . In the 32.Mari, client: “It depends on one’s own experience. It only takes a couple of babblers to make one draw a conclusion.”33.Riina, client: “I think it stresses it, being here? Being with other mental health rehabilitants, one hears these stories about how people have been stigmatized more than one would in an average workplace. Maybe, in a way, that colors the world a bit darker.”The support workers also acknowledged that the rehabilitation environment affects the way they perceive stigma (see Ext. 10–12 above). They saw a difference between the Clubhouse clients and rehabilitants in general (Ext. 34). They pondered the fact that, on average, the clients in the Clubhouse community have more serious mental illnesses than the informants in the national barometer, and that the social consequences are therefore also harder for the Clubhouse clients (Ext. 35). In addition, they reasoned that those who experience stigmatization the least are most likely to participate in surveys (Ext. 36). Although the logic is in line with research on psychiatric disorders and their social costs, cf., ,54, ther34.Varpu, support worker: “The sample matters, in a way. The sample we have here versus the sample in this (points at cards).”35.Taru, support worker: “Maybe the reason why we think like this, I don’t know, could be that the people who come to the Clubhouse, the majority of them have serious (--) psychiatric illnesses? And that is no longer a little thing.”36.Sari, support worker: “Those who experience stigma least and are active in general will also answer surveys.”What is also remarkable is that both the support workers and the clients brought forward the notion that being a client of the Clubhouse can in itself be shameful and stigmatizing (Ext. 37–40). The support workers talked about clients who do not wish people outside the community to know about their membership and will, therefore, not feature in photographs or newspaper articles, or even greet staff members or other clients outside the house . Reportedly, some clients even refuse to sit near an open window in order to avoid exposure (Ext. 38). The fear of being connected to people with mental health problems is associated with the fear of being labeled as one, which is considered shameful or unjustified . Concealing their Clubhouse membership can thus be interpreted as a measure of self-protection (Ext. 40).37.Kyösti, client: “There is probably a little stigma related to the Clubhouse as well, although it is nice to come here.”38.Sari, support worker: “If you want to put up photos on Facebook or anywhere else, people do not want their faces there. Very few dare to give their names or want to give their names. It is always the same couple of people who give interviews about things with their real names. Then again, some don’t want to sit near an open window to avoid being seen from the outside. Or you see someone there on the street and they don’t want to greet you because everyone knows you work at the Clubhouse, and so on.”39.Seija, support worker: “Some don’t want their pictures on the papers or anything else to avoid being connected to this kind of mental health place. They don’t dare walk with the group or say hello to me because someone might know that I work here and they could work it out. Many people we have here are completely healthy. They do not have anything. It is just the others who are totally (--) like, ill.”Veijo, client: “I don’t have the nerve to tell my neighbors that I visit a Clubhouse.”Kyösti, client: “No, no, no. Because it has a negative impact.”These examples illustrate what Meisenbach  calls avWhat differentiates the support workers’ accounts from the clients’ is that the support workers appeal not only to their experiences in the community but also to their professional viewpoint. Some of them reason that as professionals working in the mental health sector, they know how to evaluate the effects of mental health issues and, therefore, notice things that the rehabilitants themselves are blind to, particularly features related to a mental illness . By stating that the rehabilitants themselves are unable to recognize the features that are distracting to others, these support workers seem to imply that the stigma can “actually” be stronger than the experience reported by the rehabilitants in the barometer. Similarly, in the Finnish Mental Health Barometer, the majority (62%) of mental health professionals believed that people who experience problems with their mental health are stigmatized . To some40.Hannele, support worker: “Because we do watch them for a number of hours a day and monitor their life situations and so on (--). Could it be that this rehabilitant experiences the thing differently or does not notice it, or that we, staff members, just see and feel it? Could it be something like this?”41.Oh dear. A bit like that.”Ida, support worker: “But per se, what you (Hannele) said earlier can be true. I don’t know how to put this now so that it sounds right, but, like, if a person does not necessarily (1.5) notice that much or internalize or recognize those features, that perhaps makes us think, Other support worker groups, however, discussed the possibility that the professional viewpoint can in fact cause bias and distort perceptions. First, meeting people day to day in certain circumstances, such as in the Clubhouse or in the hospital, may affect the image of the whole reference group (see Ext. 35 above). Second, the inner process of accepting one’s illness and regaining self-esteem as a “normal person” was acknowledged to be something that the professional viewpoint does not reach (Ext. 42). Not being able to reach the perspective of the ill is also reflected in Extract 43, in which support workers contemplate whether they “get offended” on the rehabilitants’ behalf. The same group also discussed the possibility that the professionals may actually be sustaining the prejudice by believing in it (Ext. 44).42.Maikki, support worker: “Maybe the difference is in the knowledge. When you have an illness and you know about it and you know yourself, I mean, at that point when you accept it, you’d think that you are still the same. A normal person.”43.Support workers:Veli: “Do we, then, get offended on their behalf?”Ulla: “Well, I guess so.”Henna: “Probably.”44.Support workers:Henna: “Perhaps it gets emphasized at this job. Maybe. I don’t know.”Tanja: “But if WE think there is prejudice, then we MAINTAIN it.”Henna: “That’s right. Yes. We do.”Veli: “Mm, mm.”Tanja: “This is a very important question. This was enlightening.”Of note, in the last extract, Tanja describes the interviewer’s question as “enlightening”: she has become conscious of something she was not aware of before. In fact, all of the groups found the stimulated interview beneficial in terms of introspection and peer support. We will return to this notion in the concluding section.All in all, our study suggests that familiarity with mental health problems may not be as unilaterally connected to decreased prejudice as one may think based on previous research (such as ). The foIn this study, we examined how professionals and clients of mental health rehabilitation units perceive, explain, and account for mental illness stigma as a phenomenon. We also compared the ways in which the specific accountabilities connected to the participants’ more specific roles became visible in their discussion. For the methodology, we used a stimulated focus group interview that was designed to orient the participants toward reasoning. The participants were first asked to evaluate the prevalence of stigma together and then to explain their viewpoint in detail. As the method allows thinking together and comparing and adjusting views within the group, it provided us with evidence about the societal understandings and opinions that the participants in a given group are ready to support in front of their reference group. The stimulation task was beneficial in the sense that it activated the discussion and provided a way to introduce the delicate topic in a similar fashion to each group.All of the groups estimated the prevalence of experiences of stigma to be notably higher than the Finnish Mental Health Barometer . The suAfter hearing the national barometer’s result, all of the interviewed groups agreed that the level of stigma had decreased due to the development of society—unaware that the barometer rating had in fact increased. The groups talked about improvements in care and medicine, as well as the media’s role in raising mental health awareness. They also thought that stigma had diminished because mental health problems have become more common and believed that the younger generation would experience less marginalization than previous generations. The only departure from the narrative of progress with regard to stigmatization concerned the status of serious mental illnesses, such as schizophrenia. This is also reflected in the way the participants explained their particular perspective on the topic. They argued that the clients in the Clubhouse environment have more serious mental health issues than rehabilitants on the average, and that they, therefore, experience more marginalization. This idea is in line with what is known about the social costs of serious psychiatric disorders ,54, but There was also tension in the attitudes toward Clubhouse membership. Being a Clubhouse client was seen as empowering but also as stigmatizing with regard to the clients’ social status in general, which is why some of the clients keep their membership confidential. This shows that avoidance strategies  can be dAlthough the support worker groups’ conceptions of stigma were more negative than those of the clients in terms of the prevalence and the rehabilitants’ role in the experience, the focus group discussions seemed to raise awareness on the limitations of their perspectives. While considering their high estimate of the prevalence of stigma, the groups identified several possible factors that might have caused bias in their views. They noticed that the majority of their clients have a serious mental health problem, and that this affects their image of the whole reference group. In addition, they posited that as professionals, they may monitor the signs of the illnesses from a different perspective than the clients. One of the groups even considered that they might be sustaining prejudice by believing in it. Thus, sharing and comparing thoughts on the sensitive matter with the support of an outsider seemed to enhance introspection. The study has certain limitations. Given that this study was qualitative, its aim was to capture in depth the concepts that were shared in the reference groups. The rehabilitation units were selected purposively so that they would be diverse, and the interviews were continued until the saturation point was reached and recurring themes were identifiable in the discussions. However, although the sampling method provided rich qualitative information, its results cannot be considered as representative of all Clubhouses. Neither can they be uncritically generalized to apply to professionals and mental health clients in other social and health care contexts and rehabilitation environments. As the participants themselves perceived that their conceptions were tightly linked to their rehabilitation environment, it can be assumed that studying a different type of rehabilitation environment could result in different outcomes and emphasis. It is also noteworthy that voluntary participation involves the bias of some people being less likely to participate than others. In the context of mental health rehabilitation, it can be assumed that the most marginalized rehabilitants are less likely to volunteer in studies like this. Nevertheless, some second-hand knowledge about the most vulnerable groups was attained from the participants who volunteered. In any case, our results pose a challenge to the idea that familiarity with mental illness decreases stigmatizing beliefs, cf., ,52. TherWith regard to serious mental illnesses, reducing stigma is particularly challenging, as the image of these illnesses seems to entail scarce possibilities of recovering and participating in society. While we do not have a solution to this well-known issue, our data inspired us to question whether it would be more fruitful to promote acceptance of diversity rather than issue instructions to avoid stereotypes, see, e.g., . Respect


David S. Miller was Acting Scientific Director of the Division of Intramural Research at the National Institute of Environmental Health Sciences, National Institutes of Health, and Head of the Intracellular Regulation Group in the Laboratory of Toxicology and Pharmacology before he retired in 2016. David received his Ph.D. in biochemistry from the University of Maine in 1973. David was a Group Leader at the Michigan Cancer Foundation before joining the NIEHS in 1985. His research covered a wide range from renal excretory transport mechanisms to regulation of transporters at the blood–CSF and blood–brain barriers, from fish, amphibians and birds to mammals. David was an outstanding scientist with irresistible enthusiasm for science and an incredible ability to think outside the box while being an exceptional mentor and friend. Xenopus laevis, crabs, flounder, rats and mice and various model systems including oocytes, renal proximal tubules, isolated membrane vesicles and isolated brain capillaries. Their collaborative research focused on organic anions and cations and led to the major discovery that anion transport was coupled to the membrane potential through dicarboxylate exchange (mostly α-ketoglutarate) afforded by the electrogenic, sodium/potassium ATPase pump [Xenopus oocytes and fish kidneys using killifish as a model organism. In the late 1990s, his interest shifted toward transport processes in the blood-CSF barrier (choroid plexus) and the blood–brain barrier. David recognized that confocal microscopy had immense value for studying transport processes and the confocal microscope became an integral tool in his research. By the early 2000s, researchers had identified and cloned numerous ABC transporters including David’s three favorites: P-glycoprotein , breast cancer resistance protein , and multidrug resistance-associated protein 2 . David dedicated the final years of his career to identify intracellular signaling pathways responsible for the regulation of these transporters at the blood–brain barrier and contributed several seminal discoveries to the field.David S. Miller’s research career maintained a central theme of understanding how the body protects itself from toxic chemicals. This line of research was initiated during his graduate studies where he characterized the transport of toxic molecules, which evolved into studies on solute transport in various model systems. In the mid-1970s, David’s work in Dr. William B. Kinter’s laboratory linked the thinning of duck eggshells to exposure to the pesticides dichloro-diphenyltrichloroethane (DDT) and dichlorodiphenyldichloroethylene (DDE) . To undease pump . ThroughDavid Samuel Miller was born on July 24, 1945 in Brooklyn, New York City and attended Abraham Lincoln High School in Brooklyn, NY  as a model to study crude oil toxicity in sea birds. While it was known that crude oil spills caused acute toxicity and death of waterfowl, the effects of small amounts of ingested crude oil as a result of preening could now be tested revealing effects on long-term survival and potential for ultimate lethality. Again, there was a heavy emphasis on intestinal transport and Na+/K+-ATPase activity in the nasal salt gland. The work showed definitively that small dose exposure to crude oil through ingestion by sea birds produced multiple sublethal disruptions of metabolism and osmoregulatory capacity.David, as part of the Kinter and Peakall collaboration, used gull  in Salsbury Cove in the summer of 1973, shortly after he had completed his Ph.D. in Biochemistry at the University of Maine in Orono. In what would be a harbinger of the publication rate he achieved during his career; David had already published five papers when he arrived at MDIBL –34. I ha+/K+-ATPase, in winter flounder urinary bladder using 3H-ouabain autoradiography. During the very rough draft stage of writing, one of the three authors submitted a very long paragraph that lumbered and collapsed of its own accord. David wrote next to the paragraph the phrase: “E pluribus unum” (“One out of many”).During David’s 3 years as a postdoctoral research associate, I was able to interact with him on a daily basis. Although most of David’s research interests during my postdoctoral years at MDIBL (1972–1976) were different from mine, I did get the chance to collaborate with him and Larry Renfro on a study in which we localized the critical transporting enzyme, NaThe specific projects that David worked on starting as a postdoctoral fellow focused on transport processes, the cause of eggshell thinning, and the effects of various xenobiotic molecules on biological processes. David started this long list of publications with a 1975 paper in Nature [The xenobiotic transporter, MRP2, in epithelia from insects, sharks, and the human breast: implications for health and disease” [Epithelial metabolism and transport of xenobiotic and endogenous molecules” that I organized in my Cell Biology and Anatomy Department at the Medical University of South Carolina.I left MDIBL for my first position at Temple Medical School in Philadelphia in September 1976 but came back for summer research until 1980. By that time, I was working on a separate project and did not collaborate with David. I returned to summer research in 1989 with a Markey Foundation Grant from MDIBL and was able to return for summer research there a number of years until 2002 with the help of the Salsbury Cove Research Fund. By this time, David was deeply involved in organic anion secretion processes and was utilizing the powerful tool of the confocal fluorescence microscope. This instrument could detect and help quantify transport of fluorescent xenobiotic molecules and David was a master at extracting data from biological tissues with this device. David, Rosalinde Masereeuw, John Henson, and I exploited this technique to detect the excretory transport of xenobiotics by dogfish shark rectal gland tubules . We contdisease” . We founTogether, in the years from 1975 to the mid-1990s, David focused his research on excretory transport of xenobiotics in kidney, intestine, and urinary bladder of various animal models. During that time, David worked with numerous collaborators including Peakall, Kinter, Guarino, Pritchard, Holliday, Hallett, Barnes, and others including myself.+-sensitive, Na+-coupled glutarate uptake [p-aminohippurate (PAH) was driven by exchange with (α-keto-)glutarate in bladder BLM. However, indirect coupling to Na+ could potentially also drive uphill PAH transport in intact epithelium. To study the role of this mechanism in net transepithelial PAH secretion, David and John Pritchard used renal proximal tubules from Southern flounder [+/glutarate uptake and glutarate+/PAH exchange. To determine if indirect coupling affected net secretion and tissue accumulation, David and John Pritchard measured the steady-state accumulation of the anionic fluorescent dye, fluorescein (FL), and demonstrated that glutarate stimulated uphill FL entry into tubular cells and also stimulated active FL secretion into the tubular lumen. Based on this observation David concluded that FL follows the route of PAH transport. It is worth noting that David used epifluorescence microscopy and video-image analysis for these studies, which became instrumental in David’s future work.Notes from Rosalinde Masereeuw and Gert Fricker: In the 1990s, David’s research was focused on transport processes in the kidney, and he was one of the first researchers combining functional and mechanistic aspects of transport processes in intact kidney tubules , 37. Kide uptake . As in vflounder . They foFundulus heteroclitus) proximal tubules , that was custom-synthesized by Dr. Roland Wenger, Sandoz Pharma AG, Basel, Switzerland. The experiments that followed were the beginning of a long-lasting series of studies that continue until today. NBD-CSA turned out to be the ideal tool to visualize transport mediated by P-glycoprotein (P-gp), an ABC efflux transporter that had shortly prior been identified to transport cyclosporin A. In joint studies at the MDIBL, David, Gert Fricker and colleagues measured NBD-CSA transport in killifish proximal tubules  and obseFurthermore, we investigated the renal excretion of a fluorescent rapamycin derivative in isolated killifish kidney tubules , 47. We + exchanger, which was most likely what was later identified as the Multidrug and Toxin Extrusion proteins, MATE1 and MATE2-K.David observed this phenomenon for daunomycin in killifish renal proximal tubules . At pH 8Raja erinacea . Using +, whereas its secretion into canaliculi was driven, at least partially, by the membrane potential and was depended on intact microtubules.In skate hepatocyte clusters, David, Gert Fricker and colleagues also found that the microtubular network was involved in the secretion of the fluorescent bile salt derivative NBD-taurocholate . NBD-TC+-independent influx and active luminal secretion that mimicked the recently identified multidrug resistance-associated protein, MRP2, another ATP-driven ABC efflux transporter  rectal gland, which is a specialized, osmoregulatory organ composed of numerous blind-ended, branched tubules emptying into a central duct [Transport of organic anions remained David’s research focus. Using FL, carboxyfluorescein diacetate and bimane-S conjugates, he showed that organic anion excretion in killifish tubules is carrier-mediated and against the concentration gradient but not sensitive to the electrical potential difference across the luminal membrane . By thisral duct .In 1998, David published a key observation made in killifish tubules, which became important for our future studies on transporter regulation and signaling: Protein kinase C (PKC) regulation of organic anion transport suggesting direct or indirect regulation of organic anion transport at the basolateral membrane . In addiFor our studies, isolated killifish proximal tubules represented a unique model to study the regulation of transporters, in particular MRP2 and P-gp. Over several summers at the MDIBL (1998–2005), we used FL-MTX and NBD-CSA to investigate the role of the vasoactive peptide endothelin-1 (ET-1) on the functional expression of the efflux pumps P-gp and Mrp2 –62. The kidney in the brain” due to its functional similarity to renal tissue. Together with Alice Villalobos and John Pritchard, David studied uptake and distribution of the fluorescent organic cation quinacrine in primary cultures of rat choroid plexus epithelial cells [In 1999, David switched from liver and kidney to choroid plexus, an organ which is often referred to as the “al cells  and in ial cells . Since tal cells , a rROATLooking back on the transporter field of the 1990s, David’s work had an enormous impact both on our understanding of mechanisms underlying renal function as well as on the development of novel tools to investigate transport phenomena in the kidney. The combination of confocal laser scanning microscopy and isolated intact kidney tubules offered completely new perspectives to investigate transport in an experimental ex vivo system that was closer to the in vivo situation as any other model used before. Thus, it was only natural to apply these approaches for other tissues, e.g., the choroid plexus and the blood–brain barrier, as well. In 2000, David and colleagues published the first paper identifying transporters and studying their function in isolated pig brain capillaries . These rkidney in the brain”). Starting in the late 1990s, David’s interest and excitement shifted toward transporters at the blood–brain barrier, which remained his main research focus until his retirement. The first studies evolved around xenobiotic transport in isolated brain microvessels from killifish using live imaging and confocal microscopy, David’s favorite and most powerful instrument in the laboratory [Notes from Anika Hartz and Björn Bauer: Before the year 2000, David’s work was primarily focused on renal transport, but he also had some collaborations studying the choroid plexus —we unraveled an estrogen signaling pathway through which 17β-estradiol (E2) downregulates BCRP, another critical ABC efflux transporter at the blood–brain barrier , 88. We Looking back, long days in David’s laboratory were broken up by group lunches and birthday celebrations with food and cake organized by postdocs and students. David enjoyed these social events and used them as an opportunity to connect with lab members to talk about science and more. David loved to be part of these events, but he never wanted to be the center of attention.NIEHS Mentor of the Year” award; David received the award in 2006. This award is presented by the NIEHS Trainees Assembly and honors an NIEHS scientist who has made a major impact both scientifically and personally in the training of fellows and students. This achievement highlights John and David as mentors. In the nurturing environment that John and David created, we made many fond memories. Trainees from David’s and John’s laboratories found jobs around the world and while we now live far apart from each other and are busy with our lives, we are all still connected, we talk and meet from time to time and some of us even collaborate.Weekly lab meetings were held jointly between our and John’s group. In fact, we were functioning as one big group with the luxury of having two fantastic mentors. In 2004, John Pritchard won the “crazy idea experiments” that he wanted to pursue. Dusty also helped new postdocs from all parts of the world feel welcome and at home, helped them get acquainted with daily life in the lab, and she provided critical input for the perfect Thanksgiving dinner for us foreigners.During the time we were in David’s laboratory 2002–2007, David spent his summers at the MDIBL in Salsbury Cove in Maine, where we occasionally visited him to discuss data, projects and ideas. Dusty (Destiny Sykes), David’s research technician of almost 30 years, was his right and left hand in the laboratory and spent weeks of packing and shipping material and equipment to Maine each summer. Dusty was critical for David’s laboratory in many ways: she was the heart and soul of the lab and took the lead on David’s “Outside of the laboratory, David and his wife Mimi are avid horseback riders. They spent their weekends at the J&H Staples in Raleigh, North Carolina, where they boarded their horses. Both helped around the barn: they took care of the horses, cleaned the barn, enjoyed helping kids getting ready for their riding lessons, and watched and socialized with their parents during lessons. David and Mimi also took their horses out for long rides around the barn and to weekend-long riding through to nearby Virginia. They even convinced us to take up riding, which created a nice balance to the work in the laboratory. We left the NIEHS in July 2007 to take on faculty positions but kept collaborating with David on various projects while establishing our own laboratories. David hired highly productive postdocs who made significant scientific contributions in linking changes in blood–brain barrier and choroid-plexus transport to specific pathologies and xenobiotic exposures –96.do we have a scientific project to study?” It was only a question of “which one”.Notes from Ron Cannon: One late afternoon while working on the confocal microscope, I—Staff Scientist in the laboratory of Raymond Tennant at the NIEHS—happened to meet David while I was trying to localize a newly discovered transporter, ABCA13, using immunohistochemistry. David was working on the confocal and was immediately interested in my findings. We talked for about an hour as he assisted me with the appropriate confocal settings to optimize my results. Within 6 months Raymond Tennant retired and David approached me with a request to join his laboratory. I gladly accepted and I worked with David until his departure in 2015. The work with David was most enjoyable and productive. David was driven by his passion for science. Numerous nights we discussed science by phone and continued the following morning. It was never a question of finding a project. The office and late-night discussions filled the project black board in his office. There was never a question of “Most of David’s previous transporter work was focused on the blood–brain barrier transporter P-glycoprotein and how xenobiotic molecules modulated its activity. We decided to study how endogenous molecules might regulate ABC transporters like P-glycoprotein since that could be a better and more natural way in terms of treatment. We focused on how sphingolipids and ceramides regulate P-glycoprotein , 98. WorHave you talked to Dave lately? How is he doing? Tell him I asked about him and tell him we really miss him”. I think this says it all.David suffered a stroke in July 2015 and officially retired in early 2016 after more than 30 years of research at the NIEHS. He was well-known and liked by everyone. He loved scientific research; it was his passion. He mentored numerous students, post bac and post docs inside and outside of his lab. All of whom still call or sometime visit the laboratory. As I came to know him personally, I discovered his love for boating and horses. He would fly in lobsters from Maine to North Carolina for the yearly Lobster Fest at the barn where he boarded his horses. Then he would cook them in large pots as everyone anxiously awaited. He was kind and fair to everyone, no matter what their “walk” in life. Now as I walk the halls of NIEHS to attend meetings or lunch in the cafeteria, two questions and one statement are made by those who approach: “Outstanding science can be summarized in a review article. We want this tribute to David to be more than a summary of professional accomplishments. The following personal memories, thoughts and thank you notes highlight what makes David special to us as a scientist, mentor, and friend.Science aside, perhaps David’s most important contribution is his continuing good-natured irascibility, matter-of-fact no-nonsense approach to science, and contagious enthusiasm. Thank you, David, for all your help.”Larry Renfro: ““Of all the people one meets in life only a few are really special. For me, David is one of these people – not only for the rewarding scientific interactions but also on a human interaction level. There were two enormous emotional situations, one for David and one for me, in which we helped each other immensely. Fortunately, our interactions continue as David and Mimi moved to Ellsworth in 2016. For about nine years now, I have been coming to Bar Harbor, about 25 min away, and we are able to have breakfast once a week while I am here. I related several humorous stories in the text above, but I am so glad to be able to see David for a good portion of the year now. After knowing David for 45 years I still see why he is “superb”.Karl Karnaky: “I arrived in David’s lab in February 1995 as a Ph.D. student from the Netherlands who was awarded a fellowship for an international training. I could not have made a better choice in selecting a lab. David was the best mentor ever: he would patiently sit down with me to draw a serious research plan, in his own way with lots of jokes in between. His curiosity and enthusiasm was a driver in our collaborative work. He also showed how to balance between a work life and a private life. For me, he was the example of how to be a scientist and a mentor myself. Thank you, David!”Rosalinde Masereeuw: “I first met David 30 years ago at the MDIBL and for me it was one of the most important encounters in my life. His outstanding ability to explain scientific coherencies together with his most helpful and patient personal attitude made him an ideal mentor and very good friend for me. David, thank you for all.”Gert Fricker: “David infected me with his contagious enthusiasm for science. David’s assurance, continuous mentoring and his love and passion for science convinced me that science is the best. David introduced to me the concept of “thinking outside the box” by showing me the box I was trapped in – a game changer for me and most other trainees that listened carefully what he said. To complex questions David had a simple answer: “Do the right thing” – this could mean to repeat a time-consuming experiment, rewrite a manuscript or simply help a newcomer in the lab. What it gave me as a trainee was guidance, professionalism and a simple rule applicable to science and life in general. David: Thank you for doing the right thing!”Anika Hartz: “My time in David’s lab was invaluable. David had the patience to listen and always gave honest feedback: he told me the things I needed to hear, not the things I wanted to hear. To me, one of the most memorable things David said was when he received the NIEHS Mentor of the Year Award. David said: “I can’t believe they let me play in the sandbox and even pay me for this!”. Thank you, David, for the unforgettable experience. Your advice resonates with me to this day!”Björn Bauer: As I reflect on my years of working with David, I recognize his greatest ability was to lead with passion. His excitement for every project in the lab was infectious. His wide smile as new and interesting data arrived was genuine and motivating. And rather than sit alone and ponder new data, David preferred open engagement and discussions. He urged us to thinking deeply about our work and to consider its meaning and implications. What a great life lesson! Thank you, David, for being a good friend, a great colleague, and teaching us how to enjoy science to its fullest!”Ron Cannon: ““David and I first met almost 50 years ago, when he was still a graduate student with Lerner in Orono and I was a post doc in Bill Kinter’s laboratory at MDIBL. We have worked together on and off ever since. We both gained a solid grounding in renal physiology, the comparative method, and a mechanistic approach to environmental issues with Bill. I subsequently focused on isolated membrane vesicles and molecular tools, while David developed confocal and fluorescence microscopy approaches. Together we collaborated on studies of renal function and mechanisms of environmental toxicity over many of those 50 years. Not only did our scientific tools complement each other, but our work styles were similarly complementary. I was the more systematic, whereas David was more free ranging, ensuring that we looked at all the possibilities. It was a good run, and a fun one as well. I count myself as extremely fortunate to have had such a good friend and colleague.John Pritchard: Finally, I note that our lives have continued to parallel each other in recent years. David had his stroke and I, my cervical spinal injury. Happily, we have both made considerable progress in establishing a new normal, one that we continue to refine.”David S. Miller Young Scientist Award” was initiated in 2016 to honor David as a mentor, as a scientist, and as a friend. David had a positive impact on the career and life of numerous students and postdocs. He encouraged young scientists to think outside the box, sparked their interest in research, gave them valuable insights into the world of science, and guided each student along the way. The “David S. Miller Young Scientist Award” honors David’s mentorship by supporting young scientists with promising research in the brain barriers research field.The “


Housing Associations in many countries exhibit increasing levels of ‘hybridity’, asreductions in state financing for social housing, exacerbated by austerity policies sincethe 2008 crash, have instigated ‘enterprising’ approaches to maintaining income. Alongsidethis, hybrid organisations have emerged in the Private Rented Sector (PRS), responding tosectoral growth and consequent increases in vulnerable households entering privaterenting. These developing hybridities have been considered at a strategic level, but therehas been little exploration of the impacts on tenants. This article examines twoorganisations, operating across the social and private rented sectors, to elucidatepotential implications for tenants. The research suggests that different forms ofhybridity can affect tenant outcomes and, moreover, that examining such impacts isimportant in understanding hybridity itself. Furthermore, the study suggests that emergingforms of hybridity, particularly in the PRS, may be blurring the boundaries betweenhousing sectors, with implications for policy and research. In particular, Housing Associations have been examined asorganisations which are both inherently hybrid , focused on background data regardingprevious housing experiences, then at 2–4 months (wave 2) and 9–12 months into the tenancy(wave 3). Quantitative data was collected at all three waves, whilst qualitative data wascollected at waves 2 and 3, examining four aspects of tenants’ housing experience  as well ashealth and wellbeing, financial circumstances and demographics. The data from staff interviews and focus groups was analysed using Nvivo, employing acoding framework derived from characterisations of hybridity in the literature. The nextsection of the article provides a detailed introduction to the organisations and outlinesthe findings from this analysis. The subsequent section utilises descriptive statistics fromthe quantitative data  to set out the key outcome patterns for tenantsof each organisation, and then uses the qualitative data from waves 2 and 3  to explore the potential links between aspects of hybridity and tenant outcomes. Thisarticle does not focus on the longitudinal aspect of the study beyond highlighting theimpacts in terms of health and wellbeing, so quotes are identified by organisation, but notby wave.This section introduces the participant organisations and outlines their keycharacteristics in relation to aspects of organisational and modal hybridity, drawing onthe staff interviews and focus groups, together with documentation where appropriate.The first organisation is a large Community-Based Housing Association, formed by tenantsin the mid-1970s in response to demolition plans for their Council houses. It now has over5000 properties, around half of which were acquired through stock transfer within the lastdecade. The organisation operates as a relatively traditional social housing manager, notengaging with innovations supported by the Scottish Government’s Affordable Housing SupplyProgramme .However, whilst it sets rents below market rates, the influence of market pressures isevident in the higher rents for new tenants than for long-standing tenants in equivalentproperties. Moreover, all rents are increased by a set percentage, decided on by the Boardfollowing a tenant consultation, which therefore does not reduce the differential and hasa greater absolute impact on newer tenants. These higher rents create concerns aboutaffordability and tenancy sustainability in a context of welfare reform:There are varying reasons [why people move on] as you can imagine…affordability can bea reason as well. And not necessarily meaning that our rents are unaffordable. I thinkit’s more about some people move back to family because of all the cuts and changes inbenefits. These financial drivers also combine with bureaucratic structures and values which havedeveloped through organisational growth and the transfer of public sector staff. Hence,for example, property refurbishment prior to a new tenant moving in is restricted bybureaucratic commissioning systems and the risk of financial loss if tenancies are notsustained:If it’s somebody that’s older, we’ll maybe see if we can paint a room or do something.But the costs are astronomical for us to be able to paint a room… Because when you’repaying contractor rates, you know. So the difficulty is, people think that, I could getthat done for £100, so add it onto my rent. And how long do they stay, you might say,well add it over the course of 2 years, and they stay 2 months… so it's quite difficult.(Housing Association Manager)Ultimately, this leads to a managerial focus on the housing stock as a higher prioritythan the immediate needs of tenants:And the sad thing is, from a housing perspective, we’re really concerned, obviously,we’re concerned about the tenants, of course, and that’s a given. But it's our house,it's our income, and that’s the thing that we should be concerned about. (HousingAssociation Manager)There is evident tension, therefore, between the community-focused third sectorprinciples embodied in the Housing Association’s mission statement, private sectorprinciples arising from the removal of public subsidy, and public sector principlesemerging from regulation and stock transfer.For the Letting Agency, third sector principles also underly the organisation’s socialmission, summarised by the Agency’s founder as:to ensure that… vulnerable people get access to quality housing and are treated well.However, although this social mission applies across the organisation, the deliberatelyhybrid nature of the organisation leads to some differences in priorities and operationbetween the two wings, indicating tensions with private sector principles inparticular.In terms of rent levels, for the properties owned by the Agency rents are capped at nomore than 5% above the Local Housing Allowance rateit can be quite tricky if people are waiting to get a Housing Association propertybecause obviously the price of [our] rent is higher, so that can freak people out a bitMoreover, whilst the organisation aims to work with sympathetic landlords, there is aparticular tension with private sector principles in the need to retain business byensuring that landlords profit financially:really the main aim is to create happy homes and sound investments for landlords, soobviously we want the landlords to know that they’re getting the best possible qualityservice for the price that they pay, and that we’re doing what we should be to ensurethat… tenants are fit and proper to be going into the property This is particularly important because the private landlord side of the business isintended to provide a degree of cross-subsidy for tenancy support, which primarily assistsvulnerable tenants in Agency-owned properties.This tension also arises in relation to property condition, where the Agency employs aninterior designer to deliver high quality refurbishments in its own properties, but has tobalance its mission to provide quality housing with the need to grow its private landlordbusiness:We try to provide homes at the highest standard we can. The ones that we own, we havedirect control over the quality of the décor and the finishing and the safety and all ofthat. When it is landlords that we are working with we have less control and there havebeen landlords that we have turned away because the quality wasn’t acceptable. For the Letting Agency, therefore, there is clear evidence of tension between thirdsector and private sector principles. Unlike the Housing Association, however, this isless about hybridity emerging over time, but rather an inherent tension, with the moremarket-focused aspects being designed to financially underpin the socially focusedmission.The evidence regarding tenant demographics also provides some indication of drivers forhybridity, in terms of their manifestation in allocation processes and outcomes. The higher levels of disadvantage amongst Housing Association tenants compared to LettingAgency tenants in private landlord properties, in terms of the proportion who aredisabled, out of work, or on a low income, suggests an impact of prioritisation throughallocation systems, as would be expected between social housing and the PRS. The muchhigher proportion of Housing Association tenants coming from homelessness reflects therole of “Section 5 referrals”, whereby the local authority can refer homeless householdsto Housing AssociationsThis evidence from staff interviews and tenant demographics provides an initialindication of processes of hybridisation operating within each organisation, demonstratingthe value of studying these two organisations to examine hybridity and its potentialimpact on tenants. Exploring tenant outcomes within these organisations may elucidateimpacts of different aspects of organisational and modal hybridity across social andprivate rented sectors. The aim within this article is to examine what can be learnedabout impacts of hybridity within each organisation as specific examples of organic andenacted hybridisation, using the comparison between the organisations and between thetenant groups within the Letting Agency to delineate these impacts.Perhaps unsurprisingly, little evidence emerged that tenants were significantly affected byaspects of ownership and governance, despite the priority given to these in studies ofhybridity. Indeed, most tenants seemed largely unaware of these aspects of their housingorganisation. However, other aspects of the tenant experience, shaped by the ways in whichthe tensions described above play out in practice, demonstrate explicit and implicit linksto most of the other aspects of hybridity. This section considers the impacts of hybridityon key aspects of tenants’ housing experience: tenancy affordability; property quality; andhousing service and tenure.Financial drivers are clearly important alongside third sector principles in terms ofrent levels, but these feed through into organisational practices and impacts on tenantsin different ways. In terms of outcomes, however, rent levels clearly interact with the financialcircumstances of tenants. More than 90% of tenants across both organisations describedthemselves as coping with rent payments all or most of the time, although for somewhatdifferent reasons. Nearly 60% of Housing Association tenants had their rent entirelycovered by Housing Benefit, whereas only 6% of Letting Agency tenants received fullHousing Benefit, but most were able to cover their rent from their higher incomes.Where tenants do fall into arrears, however, the qualitative data suggests that theorganisations operate different approaches. For the Housing Association, financialpressures, regulatory requirements regarding financial management and the scale of theorganisation create an approach which is experienced by tenants as being relativelyinflexible:They are filing a court case against me because I was unable to pay my rent, sincerelyspeaking I didn’t pay in July… I made a payment in September… but according to themthat’s not their protocols (Housing Association tenant)By comparison, the Letting Agency is able to operate a more flexible approach in relationto its own properties, reflecting a stronger financial position and freedom fromregulation around financial management and risk:[Letting Agency staff member] says, so long as you can make your shortfall, it doesn’tmatter that you’re paying a couple of pounds a month or whatever towards your arrears,that £800. I mean… you can increase it over the next 2/3/4 years. So even with himsaying that – ‘2/3/4 years’ – then straightaway it, kind of, grounds me a wee bit more.I’m not… getting turfed out on my ear and things like that, so peace of mind andsecurity. (Letting Agency tenant)Rent levels also interact with tenants’ expectations, with Letting Agency tenantsgenerally accepting their rent as the market rate. Whilst Housing Association tenants werelargely coping with their rent, a small minority did raise concerns about the rent level.For some, this was about rent differentials within the organisation:I pay a lot more than what she does up the stair cause apparently their rents werefrozen, she's been there that long… and her rent’s frozen at £270 something. (HousingAssociation tenant)Perhaps more notably, for a few tenants, the difference between Housing Association andmarket rent levels in the area was small enough that they would consider moving to the PRSto overcome other concerns about their tenancy:I probably want to go with private renting. Everybody always says to me that it wasdaft to go private, the council’s much better, the housing associations are much better,my experiences haven’t been, so I don’t think a private landlord can be any worse, to befair… Housing Associations used to be much cheaper, now they’re not. I mean, I can get…a two bedroom for 450, so I’m going to be paying 50 pounds more a month. (HousingAssociation tenant)Hence, whilst Housing Association rents remain below market levels, this suggests thatthe financial pressures on the organisation have enforced a degree of adherence to privatesector principles, raising rent. to a level almost comparable to PRS rents, from a tenantperspective.Tenant perceptions of property quality at the move-in point are quite similar across theorganisations, as shown in Whilst the majority of Housing Association tenants were relatively happy with theirproperty, the move-in condition depends largely on how the property was left by theoutgoing tenant, and expectations are clearly important in terms of tenant's perspectives.In some cases, this was positive:I had a feeling that it could have been worse. But when they opened it, I thought thiswas a show home… I've seen, I've been in houses that…this is at the top. I thought itwould have been worse. I had all different things going on in my head, until she openedthe door. And I went, oh wow. (Housing Association tenant)Staff recognised the potential value of greater investment in refurbishment for newtenants where the previous tenant had left the property in a relatively poor condition,but significant financial and bureaucratic constraints largely preclude such work, asoutlined earlier. Hence, some new tenants were very disappointed and, in the worstsituations, this risked undermining their tenancy altogether:Like, the walls in here are pretty bad and at one point I phoned the housing officerand I says to her, listen, I'm going to have to give you that house back. That’s far toomuch work for me… I’ve nobody to help me or nothing and…there’s nothing I can do to thathouse. And I ended up saying to her, I'm going to end up just giving you your keys back,‘cause I can’t cope. (Housing Association tenant)For tenants in Letting Agency-owned properties, there was a clear impact of third sectorprinciples prioritising the quality of refurbishment, particularly where this contrastedwith previous experiences. Thus, property quality helped tenants to settle in and avoidadditional expenditure:Aye, top notch standard… basically everything in here apart from this, that and thatwas all here – couch, table, chair, fridge, everything you see was all here, very, verynicely furnished when I moved in so I didn’t have to do anything to it, just move mystuff in and find a space for it, that's it. (Letting Agency tenant)I like the fact that the flat was walk-in condition and… I didn’t have that expense ofputting new floors, new carpets, and all that, and because I wouldn’t take the kids intoa place where someone…because you don’t know whose been in it before, so I’m a bitfreaky about that… That was a big expense that I didn’t have that allowed me to…I cansave up now, I’m starting to be able to save money rather than having to get itdecorated. (Letting Agency tenant)The regulatory minimum standard for property quality is higher for social housingproviders  than for PRS landlords (the RepairingStandard). In this instance, however, financial and bureaucratic pressures prevent theHousing Association lifting properties above the minimum, whereas the Letting Agencyutilises its financial flexibility to invest in consistently high-qualityrefurbishment.Both organisations emphasise the importance of providing high quality customer serviceand support to tenants, evidenced through the Customer Service Excellence Award held bythe Housing Association and the Letting Agency’s investment in its Tenancy Supportservice. It is unsurprising, therefore, that tenants across the organisations give themhigh satisfaction ratings, as shown in The qualitative data inevitably shows a more nuanced picture, with previous experiencesand expectations playing a key role in shaping tenants’ perspectives across bothorganisations:I started my career with social housing… so I do know a bit about social housing, but[this Housing Association] have been really, really good… Hundred times better than Ithought it was going to be. (Housing Association tenant)[They’re] obviously really good at what they do, they’re not overbearing, some lettingagencies can be and they can be quite rude as well, whereas [this Letting Agency] havealways been 100% honest, genuine, nice people. I mean, they want to see you do well andbe comfortable in a house that they’ve rented you, so their attitude just seems a lotfriendlier and they show a lot more concern for their residents than anybody else thatI’ve come across. (Letting Agency tenant)For those tenants of the Housing Association who were dissatisfied, the central factorseemed to be communication, related to the scale of the organisation:And I ended up having to deal with [the repair issue] when I was in my work, and I wascrying down the phone. I was like, I'm so stressed out at repeating myself; anddifferent people telling you different stories all the time… So, at the start of this Iwas dealing with one housing officer, but then she left and the new one was yet to behere. So, I don't know if that's maybe made a difference? There's not one person dealingwith it. (Housing Association tenant)Across both organisations, satisfaction was at least partly related to tenants’ sense ofsecurity in their tenancy. For Housing Association tenants, this was underpinned by thesecurity of a lifetime tenancy agreement:Once you go over the door it’s just like, do you know this is my flat, it feels good….because when we were looking at private lets, it was like renewing contracts and stufflike that which was kind of daunting. Whereas as long as we make our end of the dealthen the flat's ours. (Housing Association tenant)For tenants in properties owned by the Letting Agency, the reassurance given by staffcreated a similar impact, particularly with positive communication at the end of theinitial, standard 6-month tenancy period:I think I feel better in general, I suffer from anxiety and stress in the past, I wasalso on medication, that was before last year, it was 2 years ago, and I woulddefinitely say that that has improved… [the housing is] definitely one of the factors,you know, not having to stress about where you live is a good thing. (Letting Agencytenant)Indeed, for some tenants, the Letting Agency seemed more like a social housingprovider:In previous houses, private lets and that and… I didn’t have the same service, kind ofthing, you know. It’s just a totally different group that I’m working with this time,the housing association… I haven’t heard of a housing association like them wherethey’ll actually come out and, you know, be as hands on with their tenants and…in apositive way rather than pressuring the tenants. (Letting Agency tenant)For tenants across both organisations, therefore, the priority given to customer serviceand tenancy support provided a positive, secure housing experience which helped tounderpin a sense of home. This in turn led to improvements in tenants’ overall quality oflife and, ultimately, their health and wellbeing:Because I’m comfortable in here, eh, I can go and start doing things, like some acting,you know, or even just go for a walk, or a drive, or jump on a bus. You know, 'cause I'mnot in a lot. Because I am still pretty new to Glasgow, so, 'cause I still have the freebus pass, I use that a lot, you know, to get to know the city, and stuff like that.(Housing Association tenant)Well, the fact that they are looking out for my own wellbeing kind of helps me getthrough. I mean, money’s stressful, especially when it’s tight. So, when you know yourlandlord is not just, you know, wanting the money through the door every month, he’sactually hoping that you’re okay and you’re able to afford it, it’s reassuring. Ithelps, you know, keep the stress levels down. (Letting Agency tenant)These impacts on health and wellbeing were measurable, as illustrated in et al., Indeed, other data suggests that positive housing experiences for disadvantaged tenantscan play a role in addressing health inequalities. The World Health Organisation 5-pointwellbeing scale (Topp This evidence suggests, therefore, that third sector principles shape frontlineinteractions between tenants and staff in ways that have significant positive impacts ontenants. For the Housing Association, there is some evidence that scale and bureaucracy,perhaps influenced by a pervasion of public sector principles, may undermine thesebeneficial outcomes in some instances, although state influence in terms of tenancyregulation is experienced more positively. For the Letting Agency, the diffusion of thirdsector principles through the tenancy support service and approach to tenancy security,creates an experience for tenants in Agency-owned properties on a par with social housing.Whilst private sector principles are clearly more dominant for tenants in private landlordproperties, there is no evidence that this undermines tenant satisfaction orwellbeing.The following section draws the findings together and explores their implications for theexamination of hybridity in housing organisations, and for the future of the housingsectors in Scotland.The relationships between aspects of hybridity and tenant outcomes are inevitably somewhatcomplex, given the wide range of factors at play. Changes unrelated to hybridity can occurwithin organisations, with implications for tenants, whilst the kind of self-rated tenantdata used in this study is subject to external influences, not least tenants’ previoushousing experiences. Nevertheless, it is possible to identify areas where organisational ormodal aspects of hybridity seem to be relevant in shaping impacts on tenants.For the Housing Association, values established by the tenant-led origins of theorganisation place its roots firmly in the third sector Billis, . Principet al., Often, however, the third sector principles are in tension with private sector principlesarising from changes to market-based financing, which drive towards higher rents, strictarrears protocols and limited investment in property refurbishment for new tenants. Aspectsof bureaucratic structure and processes also seem to play a role in shaping servicestandards, but it is less clear whether these are driven by market pressures, public sectorvalues arriving with transferred staff, or simply an inevitable consequence of increasingscale. Indeed, all of these factors emerged during focus group discussions with staff at theend of the project, suggesting that there are multiple drivers operating at different pointswithin the organisation. Arguably the protocol-based, somewhat impersonal servicesexperienced by a minority of tenants are evidence of emerging New Public Managementprinciples (Sprigings, For the Letting Agency, evidence from the differences between the tenants in owned andprivate landlord properties, in terms of tenant characteristics and levels of service andproperty satisfaction, indicate the forms of hybridity within the organisation. Third sectorprinciples encapsulated in the Agency’s social mission clearly drive prioritisation withinallocation processes, rent levels, investment in property quality and the central focus ontenancy support. For tenants in properties owned by the organisation, there is a degree oftension between this social mission and market pressures which, for example, preclude thepossibility of keeping rents below benefit thresholds. However, these tensions with privatesector principles are more obvious in relation to private landlord properties, where theAgency has to balance tenant needs with profitability for landlords, and the widerorganisational requirement to maintain this aspect of the business to cross-subsidisetenancy support.By contrast with the Housing Association, these elements of hybridity are more consciouslyenacted Billis,  within tPerhaps most notably in terms of tenant experiences and outcomes, the Letting Agency'sapproach to tenure within its own properties demonstrates an implicit form of modalhybridity. Whilst participants in this study were legally no more secure in their tenancythan any other PRS tenant, the level of reassurance given by the organisation made them feelas if they were in a lifetime tenancy, equivalent to social housing.et al., This study aimed primarily to examine the impacts of hybridity on tenants within eachorganisation, rather than to compare them. Differences in demographics and previous housingexperience make comparisons between the groups of tenants challenging, whilst the complexpatterns of hybridity make for particularly convoluted causal connections. Nevertheless, theevidence of relatively greater improvements in health and wellbeing, as well as satisfactionwith service and property quality, amongst tenants of Letting Agency-owned properties bycomparison with both Housing Association and private landlord tenants suggests someinteresting possibilities in terms of modal hybridity. Indeed, the blurring of tenure andrent boundaries from a tenant perspective suggests that hybrid housing organisations withinthe PRS may have the potential to play an important role in responding to the excess demandson social housing (Powell The evidence from this study also demonstrates that aspects of hybridity can havesignificant effects on tenants’ housing experience where market or state pressures constrainthe social mission of third sector organisations. Where such processes of hybridisation feedthrough into higher rents, or depersonalisation of services, this can affect not justtenants' satisfaction with their tenancy, but ultimately their wider wellbeing and qualityof life. Such findings suggest that research on hybridity in housing organisations needs toextend beyond a focus on structure and strategy Gruis,  to underThis study explores just two specific examples of housing organisations within onenational context. Hence, further studies of a wider range of organisations acrossdifferent contexts would be beneficial to expand the understanding of tenant outcomes ofhybridity.The prioritisation of tenant data within the study also places some limitations on thelevel of detail in the organisational data. Additional research would be valuable, placinga greater focus on the links between external and internal drivers of hybridisation, thespecific patterns of hybridity created, and the ultimate impacts on tenants. Within this,longitudinal explorations of the shifting nature of organisational values and the‘elective’ elements of hybridity in management decision-making would be useful. Moreover,exploring the impact of regulation and emerging hybridity which may be shifting thesocial-private boundary in rented housing would be particularly useful for a range ofaudiences.


Learning is increasingly seen as an essential component to spur progress towards universal health coverage (UHC) in low- and middle-income countries (LMICs). However, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. Specifically, it appears that ‘learning for UHC’ is dominated by the teacher mode — notably scientists and experts as ‘teachers’ conveying to local decision/policy-makers as ‘learners’ what to do. This article shows that, to meet countries’ needs, it is important to acknowledge that UHC learning situations are not restricted to the most visible epistemic learning approach practiced today. This article draws on an analytical framework proposed by Dunlop and Radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. These learning modes look relevant to help widen the learning prospects that LMICs need to advance their UHC agenda. Actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry. Advancing universal health coverage (UHC) to improve population health is a long-term objective that many low- and middle-income countries (LMICs) have committed to. Since the release of the World Health Report 2010, entitled ‘Health systems financing: the path to universal coverage’ ; assess Yet, there is not much scientific literature on learning processes related to UHC  and quesgroups of people who share a concern, set of problems, or a passion about a topic, and who deepen their knowledge and expertise in this area by interacting on an ongoing basis” ;  basis” r time” .roblems”  and alsoIn the next sections of this paper, we first give a (non-exhaustive) overview of the literature on learning and how we came up to adopt the analytical framework by Dunlop and Radaelli . ThereafNavigating the literature on policy learning is a daunting task since the latter is ‘characterised by concept stretching’ , 25, 26 politics finds its sources not only in power, but also in uncertainty – men collectively wondering what to do” tainty”  itainty” , ontext”  and more focused on the characteristics of the policy process that determine varieties or modes of learning” .arning” venues” venues”  someone who ‘knows’ and someone who is likely to learn, (2) intractable policy issues looking for technocratic answers. ‘Expert power’  is actuaucrats” Dunlop and Radaelli’s approach to policy learning modes enriches the field of public policy analysis by highlighting the role of learning in policy-making and decision-making spaces, both conceptually and empirically. This is relevant from the UHC perspective regarding the critical role that learning could play in UHC processes, especially with the complexity of health systems , 7. Our Epistemic learning is probably the most visible, analysed and rationalised mode of learning today in global health . This isEpistemic learning can also take a more active form, for instance, as technical assistance to countries in various possible arrangements — ‘fly-in/fly-out’ or long-term technical assistance , with loIdeally, these scientists and experts should be people familiar with the technical and non-technical  intricacies of the context — a condition not always fulfilled , 59. TheScientists and experts can also be seen just as useful contributors to policy processes. This situation is encountered in some middle-income countries ; an issudémocratie sanitaire” [health democracy] in the francophone system — that is, a process promoting citizen participation in health policies development and implementation through consultation, public debates and dialogue [It seems to us that the international UHC community has so far paid little attention to this second mode of learning. In reality, it is taking place but it is not highlighted in the literature nor made explicit. In the context of UHC, a typical example of reflective learning could be the learning that emerges from what is coined “dialogue . Actualldialogue , 67. Thedialogue . Indeed,Concretely, this learning mode seems little used in countries where decision-making is highly centralised. Indeed, reflexive learning in some way would constitute a kind of ‘endangerment’ as it involves losing some control over the policy process. The National Health Assemblies in Thailand, originating from the concept of the ‘Triangle that Moves the Mountain’   the adoption (or not) of output-based financing mechanisms ; (2) theRégime d’Assistance Médicale; a health coverage scheme for the poor) options, each bringing their own knowledge and experience [Learning through bargaining focuses on the preferences of stakeholders  and stemperience . Bargainperience , 82.In the context of UHC, learning in the shadow of hierarchy emerges from the very exercise of public authority. It is therefore practiced by all health authorities, although in varying ways and quality. Hierarchical learning is particularly cherished by disease programmes and international agencies with an operational mandate such as UNICEF. Indeed, like epistemic learning, hierarchical learning is directed and prescriptive. It corresponds to the situation where an actor uses his/her/its ‘legitimate’, ‘coercive’ or ‘reward power’  to purpoIn any case, the quality of learning will depend on the compliance of the governed, the clarity on the roles of stakeholders and the effectiveness of instructions. Such learning, for example, is supported by field supervision visits, good monitoring and evaluation systems with adequate metrics to analyse policy actors’ performance, or annual policy reviews. It thus values deliverables and measurable results. Generally, knowledge is acquired both by the person holding authority who provides supervision or performs the monitoring and by the ‘street-level bureaucrats’ who make the effort to understand the instructions. Learning can be enhanced if the supervisor is able to take advantage of the lay knowledge of the grassroots actors and not necessarily believe that his/her own hierarchical position or seniority means superior knowledge.In fact, hierarchical learning can be supported through the proper use of internal routine data. This is probably one of the great learning opportunities that remains minimally exploited for UHC . FurtherSeveral important points emerge from our research. It has shown that there are many ways to learn, materialised by the learning modes proposed by Dunlop and Radaelli. In-depth analyses of what mode(s) of learning is occurring, with whom, when, where, why, how, at what level and with what results, in relation to specific UHC processes in LMICs, deserve being empirically investigated and, we trust, will be the subject of future research. Further research exploring their triggers, constraints and pathologies  would alLearning for UHC naturally occurs. However, learning can also be organised or directed. Among ‘UHC promoters’, there seems to have been so far an operational bias towards epistemic learning, often under a teacher–learner model. It is undeniable that this learning mode demonstrates some effectiveness to tackle technical knowledge and capacity gaps in many LMICs, but this bias possibly stems also from power structures or unchallenged assumptions . In any case, there are probably missed opportunities — countries do not leverage the large array of learning situations that have great potential to spur their progress toward UHC. Today, too few ministries or technical departments are purposely investing in their own systemic learning capacities –12."learning changes in nature across the different stages of the policy process" — our study allows to deepen this subject matter by highlighting a grid to better categorise and analyse these different moments of learning. It would also be compelling to investigate what learning modes are mobilised or emerge at each stage of the strategic planning process, as proposed by WHO [Beyond the illustrations we provided in this paper, applied work is needed to know more about what learning modes occur, when, where, how, at what level and under what circumstances. For instance, Akhnif et al.  already d by WHO . Furtherd by WHO  and furtOther studies could also explore the contribution of different hybrid models, that is, varying degrees of mixtures of different learning modes. Indeed, learning modes are not mutually exclusive; they co-exist, occurring sometimes at the same time. A good example of a hybrid model is the ‘coaching and mentoring’ support provided by the Strategic Purchasing Africa Resource Centre (SPARC) to an Expert Panel of Kenya’s National Hospital Insurance Fund to comfort it as a strategic purchaser of health services . This exThis paper aimed at illustrating the possibility and relevance of using the concept of ‘policy learning’ to analyse learning in UHC processes in LMICs. Dunlop and Radaelli’s framework allowed us to throw a new light on existing processes but also to widen the learning prospects that countries could tap into to advance their UHC agenda. The new perspectives highlighted in this article also echo implementation activities or research carried out by multiple actors involved in the field of learning for UHC — they could validate certain hypotheses, clarify grey areas and, above all, spark new reflections and ideas.All in all, there is room for action and building countries’ systemic learning capacity for UHC. However, establishing an ambitious research and learning programme is crucial. Our contribution fits in this voluntarist perspective.