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By analysing debates between member states of the World Health Organisation (WHO) over health inequities experienced by sexual and gender minorities (SGMs) from 2013 through to 2015 and 2016, this paper interrogates a WHO decision to 'do nothing', and the relationship between this decision and the production of ignorance and non-knowledge. This paper problematises state representatives' discursive practices regarding the lack of evidence on SGM health inequalities, drawing on the sociology of ignorance. Informed by the sociology of nothing, two analytical categories – non-recognition (omissive) and mis-recognition (commissive) of SGM communities – are proposed to critically understand the production of 'no-bodies' and the tolerance of the lack of evidence. The lack of evidence, rather than prompting WHO action, was used as a rationale for intentionally neglecting the health concerns of particular social groups due to their invisibility in health research. Therefore, the paper argues that the lack of evidence in itself is symptomatic of the existence of SGM health inequities, which require the WHO to take action such as formally expressing concerns about and endorsing research on the topic. [ABSTRACT FROM AUTHOR]

This paper examines how Ebola survivors in Sierra Leone are enacting biological citizenship to effect responsive and accountable engagement with their government. Disaster survivors are often left without avenues to hold policymakers accountable, but, recently, injured or disabled people have taken legal action against their governments over issues such as negligence, delays, damaged property, and death. However, in Sierra Leone, members of the Ebola survivors' association have sued the government at the ECOWAS Community Court of Justice over a less conventional issue: corruption. After audit reports uncovered instances of financial impropriety that compromised the country's response to the 2013–2016 Ebola outbreak, two plaintiffs sued the government with the argument that corruption and the failure of the government to hold the culprits accountable constitute abuses of the rights to life and health of those affected by the disaster, and the entire population. Based on this case, the paper argues that the lawsuit is an attempt to redefine corruption as a health hazard and a human rights violation. This challenges authorities to give serious attention to how financial improprieties affect the ability of state agencies to guarantee equitable, dignified healthcare, and to take the post-disaster rehabilitation of survivors as a critical component of reconstruction programmes. Ultimately, the lawsuit might set a precedent for other disaster survivors to demand equitable and dignified access to health and proper rehabilitation. This paper draws on scholarly literature, official documents, and conversations with some of the survivors and their lawyer to make this argument. [ABSTRACT FROM AUTHOR]

Health care systems around the globe are currently orienting themselves towards 'personalized medicine', a medical care regime aimed at individualizing prevention, diagnosis, and treatment of disease through proliferating amounts and sources of data, including genetic information. In Denmark, national health policies on personalized medicine focus on harnessing the potentials of genomic science and technology to bring knowledge about patient-specific genetic variation into clinical application. A major hope is to improve public health and prevent common diseases by integrating genomic information in health care, yet to act preventively, a temporal path has to be established defining what kind of knowledge to create and to act upon, and when. This paper explores the temporal orderings of medical knowledge in two different areas: health policy and clinical practice. Examining policy papers on personalized medicine issued by Danish governmental and research institutions, and, comparing them with contemporary practices of using genetic information in preventive cardiac health care, we demonstrate that genetic knowledge-making is ordered around two different conceptual views of time: namely the sequential order and the speed with which such knowledge is produced. We argue that the visions of knowledge-making and early intervention through genomic science and technology as conveyed in policy papers on personalized medicine, challenge preexisting practices and understandings of what constitutes timely prevention and actionable knowledge within clinical care. We close the article discussing how prevention through genomics amplifies the significance of the clinical space for public health as a site for sense-making and translation of controversial genetic knowledge. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic has disrupted societies globally. Public health institutions were tasked with responding to the pandemic in a dynamic and uncertain context. This paper sheds light on the experiences of COVID-19 response actors as they navigated multi-dimensional crises associated with the pandemic in general and vaccine hesitancy in particular. This research was conducted during the initial phase of the COVID-19 vaccine rollout in Flanders, Belgium. Participants included informants across all levels of the COVID-19 vaccination strategy including but not limited to those producing scientific knowledge, providing policy input, or implementing public health directives locally. 'Crisis' was identified as a recurring theme in interviews with informants. The paper highlights multi-dimensional crises experienced by informants such as the: (i) crisis of prioritization, (ii) crisis of communication, (iii) crisis of the changing image of science, (iv) crisis of epistemic agency and autonomy, and (v) crisis of trust. [ABSTRACT FROM AUTHOR]

In some countries, far-reaching 'lockdown' measures to contain the spread of coronavirus were implemented early in 2020. In Austria, these early measures were met with a high degree of compliance among the country's population. In this paper, we draw upon qualitative interviews, and ask how people made sense of the restrictions imposed during the first lockdown in April 2020 and what shaped their compliance. Empirical research has so far tried to explain compliance by means of people's disposition and motivations as well as demographic and social characteristics. Instead of focussing on who is compliant, we aim to understand how people practice compliance. We do this by approaching compliance through the concepts of values and practice. First, our findings indicate that people assess whether measures are suitable and legitimate in relation to the values of science, the law, and morality. Second, people assign additional personal value to compliance by stressing its positive implications on their own lives. By adopting a nuanced perspective on compliance as inextricably linked to peoples' values and practices, our paper critically contributes to the political and scholarly discussion of pandemic public health measures. Understanding compliance through the lens of values shows how people make sense of the measures in the context of their everyday lives, helping us to move away from a binary understanding of (non-)compliance that has become morally charged. [ABSTRACT FROM AUTHOR]

Global health organisations are increasingly involved in large-scale health interventions in countries in the Global South, partnering with states to implement programmes to strengthen national health systems and promote Universal Health Coverage (UHC). Drawing on an ethnography of a large-scale global health partnership between the Zambian state and the Clinton Foundation, this paper examines the novel configurations of sovereignty that are created by these large-scale global health partnerships. It shows how officials from the Clinton Foundation came to believe that senior Zambian government actors had granted them the authority to implement the programme outside of the formal channels of the government health system. I conceptualise this as an informal mode of 'outsourcing sovereignty' and show how it led Clinton Foundation employees to behave as de facto state actors in rural Zambia. This paper contributes to the broader critical task of describing and analysing new forms of governmental pluralism in contemporary global health and highlights some of the politically troubling consequences when sovereignty is informally outsourced in this way. [ABSTRACT FROM AUTHOR]

In this paper, we view health strategies in the field of personalised medicine as performative actions which articulate the development desired for a given society and demonstrate and affirm values and visions for that society. Based on a qualitative study in Denmark, we show how political actors and policy documents articulate visions for personalised medicine through a distinct sociotechnical imaginary. This sociotechnical imaginary mobilises the distinction between non-profit public and for-profit private organisations, placing personalised medicine in the public domain as the self-evidently desirable future for Danish health care In the Danish case, the issue of implementing personalised medicine becomes an opportunity to revisit the vision for the welfare state and verify public institutions as a shared space for state and citizens. While Danish political actors see personalised medicine as transformative, they articulate this transformation as being steered by public actors, at the same time downplaying the role of private companies. Where public health studies have focused on how political investments into personalised medicine may marginalise specific groups and populations, the Danish case shows that also powerful transnational players may be excluded from political discourse. It teaches us not to treat personalised medicine as one phenomenon, but to pay direct attention to the local contexts in which it operates and shapes what 'public' and 'health' become. [ABSTRACT FROM AUTHOR]

Rigorous evaluations of the effects of vertical public health enterprises on the health systems of low-income countries usefully identify the public health and ethical costs of those initiatives. They reveal that such narrowly focused public health ventures undermine the efforts of those countries to establish and maintain adequately resourced and well-developed national health systems, including comprehensive primary care programs. This paper argues that the scope of assessments of vertical public health ventures should be broadened to include gender as an additional axis of analysis. When members of socio-economically marginalized populations are sick with conditions that are not covered by fragmented and inadequate public health programs or disease-specific vertical public health schemes, their untreated illnesses add to the gendered familial caregiving responsibilities of the female members of their households. Those women and girls have to perform their 'normal' familial care work, work outside the home for pay, and take care of the unwell family members for whom the household cannot afford treatment. Given that women and girls from low-income households already shoulder a disproportionate amount of care work for their families, their health and life prospects are further affected by the amplification of their caregiving responsibilities. This paper argues that analyses of the impact of vertical public health initiatives should also track this gendered consequence of those enterprises because it is a crucial public health and ethical matter. [ABSTRACT FROM AUTHOR]

This paper explores the joint roles of law and biomedicine in constituting the boundary between legitimate and illegitimate (and genuine and 'pseudo') traditional healing. It argues that, as law and biomedicine have grown to share common understandings of the nature of knowledge, they have come to act as converging colonizing forces that displace and alter 'other' forms of knowing and ordering. Even as regulatory systems set out to recognize some forms of traditional medicine, they continue to operate on assumptions that disqualify knowledge, products, and actors, that do not resemble their biomedical counterparts. This leaves traditional healing systems potentially having to either operate outside the law or adapt to it by transforming themselves, potentially beyond the point of recognition, to fit better into the systems provided by law and biomedicine. The paper explores the series of dilemma this creates for those seeking to 'regulate better' traditional medicine. [ABSTRACT FROM AUTHOR]

Noncommunicable diseases (NCDs) are a complex category composed of five diseases and five behavioural and environmental risk factors. These are, in turn, represented by multiple constituencies and communities of expertise and interest. This fractured landscape is evidenced by and magnified through an abject lack of conferences devoted to the category of NCDs. One of the very few is the NCD Alliance Forum, most recently held in February 2020 in Sharjah, United Arab Emirates. With the first Forum held in 2015 and another in 2017, these events offer powerful insight into the key actors, advocacy strategies, debates and aspirations of those working in the 'NCD space'. Using the Forum as its object of research and analysis, this paper critically reflects on two persistent questions facing NCD advocates. First, how might NCDs be more like infectious diseases in cultivating a sense of urgency and action? Second, is NCD advocacy a 'movement' or a 'community' of loosely connected actors? Set against the emerging COVID-19 outbreak, which at the time of the Forum was limited to China and a handful of other countries, the Forum offered a unique opportunity to reflect upon the significant challenges facing NCD advocates across global north and south. COVID-19 only highlights how rising rates of NCDs have made global populations vulnerable to emerging infectious diseases. Yet, as the paper concludes, with the COVID-19 pandemic continuing to rage, the future of NCD advocacy and funding looks ever more fragile even as evidence of its need continues to grow. [ABSTRACT FROM AUTHOR]

'Complexity' is theorised as a characteristic of modern food systems that poses a challenge to improving population diets. This paper seeks to explore the discursive deployment of 'complexity' in the context of public health. Doing so helps inform a more critical assessment of commercial and political determinants of health, and of 'complexity' as a prevailing frame for public health issues. Qualitative methods were used to explore 'responsibility' for healthy eating in the food system in the United Kingdom. Discourse analysis was conducted on corporate and government documents, and interviews with industry and government stakeholders. The aim was to examine the implications of 'complexity' within discourses of dietary public health. 'Complexity' was used not only to characterise dietary public health problems but also as a rhetorical device in public health narratives. It performed two main discursive functions: firstly, to represent diet-health problems as so multi-layered and difficult that they are intractable. Secondly, and despite this acknowledged complexity, to deflect from food system actions for improving diet to 'simpler' and non-food interventions, by industry and government. These uses of 'complexity' serve to attribute primary responsibility to individuals for dietary choice and to obscure inaction by government and industry, who have most control over the determinants of those choices. In short, 'complexity' can be used discursively to generate a smokescreen masking policy inaction in addressing public health problems. [ABSTRACT FROM AUTHOR]

Persistent health inequalities pose a challenge to researchers and policymakers. Decades of research have illuminated mechanisms that underlie health inequalities, now we must move beyond these observations to enable policies that can reduce them. In this paper, we highlight tensions in the field of health inequalities research regarding the relationship between social determinants and health outcomes, and the effectiveness of welfare policies. We draw on recent evidence to analyse and discuss these areas of debate and provide insight into the evidence on causality, welfare systems and policies aiming to address the social determinants of health inequalities. First, we examine the evidence that inequalities in the social determinants of health are causally related to health inequalities. Second, we discuss whether more egalitarian social policies provide a solution to redressing health inequalities. In conclusion, we suggest that current debates around causal understandings risk sending the field down 'rabbit holes' that distract from solution. We argue that, if we combine epidemiological evidence with the broader canon of social science evidence, the case for causal inference is sufficiently strong to suggest we now need to focus on effectively supporting and promoting research-informed policy responses to health inequalities. [ABSTRACT FROM AUTHOR]

Since the outbreak of the global financial crisis that started in 2007/8, austerity measures have been promoted in many European countries. Frequently justified as a form of crisis-management, these measures have been used to further privatise and deregulate welfare systems, as well as to reinforce the isolation of certain decision-making arenas from democratic processes. At the same time, they have also generated new strategic opportunities for resistance to different forms of anti-austerity disruptive agency. The paper analyses the rescaling strategies implemented in public health services in Spain and the UK during the current economic crisis, and contributes to the understanding of the scalar dynamics and strategies of two social struggles against the privatisation of hospitals and health centres in these two contexts: Marea Blanca (White Tide) in Madrid and Keep Our NHS Public in Greater Manchester. It argues that social movements are more successful when they exploit scale shifts to transform institutions into centres of resistance. [ABSTRACT FROM AUTHOR]

Discourse regarding public health problems disproportionately affecting marginalized communities may shape and sustain health inequities. Analyses of news media and public health communications in the wake of infectious disease outbreaks provides opportunities to examine how discourse produces dominant public perceptions about the drivers of health emergencies and who is responsible for protecting community health. Guided by Bacchi's "What is the Problem Represented to Be?" analytic approach, this paper critically examines the discursive construction of problems and solutions in news media (n = 35) and public health communication (n = 18 press releases, n = 1 governmental report) regarding an unprecedented hepatitis A outbreak in San Diego, California, USA (2016–2018) that disproportionately affected people experiencing homelessness. We organize our findings around three elements of problem and solution representation with respect to the outbreak: 1. The inequitable attribution of risk and deservingness; 2. assumptions divorced from socio-structural factors and perspectives of marginalized populations; and 3. political theatre as a means of blame-shifting and (in)action. Overall, our findings suggest that even when structural-level issues were acknowledged within news media and public health communication as undergirding the 'problem' of the hepatitis A outbreak, outbreak discourse focused on individual-level responsibility for both the causes of and solutions to it (e.g. vaccines, criminalization of homelessness), and on shifting blame between government actors. These findings have implications for understanding the role that news media and public health agencies play in shaping public perception of the causes, consequences and solutions to infectious disease outbreaks that disproportionately affect marginalized populations. [ABSTRACT FROM AUTHOR]

The word 'vulnerable' is frequently used in public health research and practice. We use critical discourse analysis to explore the use of this term in articles published between January 2015 and January 2018 in the American Journal of Public Health and the Canadian Journal of Public Health. We find that terms such as 'vulnerable groups' are often vaguely defined or undefined, requiring the reader to 'fill in the blanks' as to who is vulnerable, why they are vulnerable, and what they are vulnerable to. Where terms such as 'vulnerable groups' are applied with some specificity, they are used as proxies for a wide range of groups, conditions and situations. Often, groups are constituted as inherently vulnerable, as authors imply that even if policies and processes change, group vulnerability will remain. Notably, populations and groups in power – and therefore responsible for generating structural vulnerability – are rarely examined. In our experience, researchers often use the word 'vulnerable' strategically to attract resources, policy interest and public concern. At the same time, we propose that the vagueness associated with terms such as 'vulnerable' conceals the structural nature of public health problems. We conclude that this vagueness can serve the political function of obscuring power relationships and limiting discussion of transformational change. [ABSTRACT FROM AUTHOR]

Racism and government policies of colonisation and assimilation contribute to the disproportionate burden of disease carried by indigenous people globally. In colonial contexts such as Aotearoa New Zealand, these inequities are routinely monitored but governments believe economic growth and better lifestyles will resolve the issues. Stop Institutional Racism (STIR), a group of health activists, is challenging this dominant discourse and building a boutique social movement to transform racism within the New Zealand public health sector. Central to the work of STIR is partnership between indigenous and non-indigenous practitioners underpinned by Te Tiriti o Waitangi – the founding document of the colonial state of New Zealand. This paper reflects on STIR organisational processes and political achievements to date. We have worked towards mobilising the public health sector, re-energising the conversation around racism and strengthening the capacity and evidence base of the sector around key sites of racism and anti-racism praxis. This paper will be of interest to others within the global public health community who are looking for new collective ways to organise and challenge entrenched inequities. [ABSTRACT FROM PUBLISHER]

This paper explores public health policy implementation through partnership working at the local level by examining how local actors from public health, and the wider workforce make sense of and work on social inequalities in health. An ethnographic case study was used to examine policy implementation in one local strategic partnership in north-west England during a period of significant resource constraint. Semi-structured interviews were the primary method of data generation. Sensitising concepts from figurational sociology were used to develop a theoretical account of how local policy implementation directed at narrowing social inequalities in health tended to give rise to relatively fragmented and short-term services, projects and practices, which focused on lifestyle factors and behaviour change. Theorising partnership work as figurations goes some way to explaining the apparent paradox among participants who expressed a relatively detached appreciation of wider social influences, alongside emotional involvement in their work. This process of individualisation explains how local professionals tended to conceptualise health inequality and the social determinants of health as personal troubles. Individualisation meant that the social reality of working in partnerships on difficult issues was simplified. Thus, any scope for working on the social determinants of health tended to be overlooked. The extent to which this was intentional or a matter of struggling to see opportunities, or a mixture of the two, was difficult to discern. Although the policy landscape has changed, the findings give some insight into understanding how local collaborative processes reproduce local public health work underpinned by lifestyle choices. [ABSTRACT FROM AUTHOR]

Two decades since the WHO Regional Office for Europe outlined and published a report on health promotion in prison, which stimulated further debate on the concept of the ‘health promoting prison’, this paper discusses the extent to which the concept has translated into practice and the extent to which success has been achieved. This paper primarily focuses on why there has been a gap between the strategic philosophy of health promotion in prison and practical implementation, suggesting that factors such as ‘lifestyle drift’ and public and political opinion have played a part. A further argument is made in relation to the overall commitment of European countries and more broadly WHO in their support of settings-based health promotion in this context. It is proposed that there has been a weakening of commitment over time with a worrying ‘negative trajectory’ of support for health promoting prisons. The paper argues that despite these challenges, the opportunities and potential to address the needs of those who are often most vulnerable and excluded is colossal and acting to tackle this should be a greater priority. [ABSTRACT FROM PUBLISHER]

Public health advocates aim to maximise affordable access to good quality essential medicines. This goal often conflicts with the profitseeking ambitions of the pharmaceutical industry. Since the World Trade Organisation's Trade-Related Aspects of Intellectual Property Rights agreement, the extension and enforcement of intellectual property (IP) rights has become the dominant discourse in global medicines governance. Public health advocates operating within this framework face significant obstacles and challenges. This paper presents an historical perspective to the contemporary debate over medicines and patents by examining the evolution of international medicines governance between the 1940s and 1970s. This research indicates that debates around IP and medicines were more advanced in terms of equity and access in the 1960s and 1970s than they are today. While acknowledging the existence of obstacles and challenges for advocates, the paper argues that alternative frameworks can and should be reasserted in global debates about medicines governance. [ABSTRACT FROM AUTHOR]

Scotland is faced with pernicious health inequalities, which stem from inequalities in living conditions and the societal structures that create them. While action is needed to address the wider structural causes of health inequalities, the role of general practitioners (GPs) merits attention due to health care's potential to mitigate or exacerbate health inequalities. Minimal research, however, has explored how GPs understand the fundamental causes of health inequalities nor how they conceptualise their role in mitigating these. This paper aims to fill this gap using in-depth qualitative interviews with 24 GPs working in some of Scotland's most socio-economically disadvantaged, urban areas. Using Raphael's SDH discourse framework, this paper found clear linkages between GPs' perceptions of their patients, how they defined the 'problem' of health inequalities, and what they thought could be done to tackle them in disadvantaged areas. In general, there was convergence on how interviewees viewed their role in mitigating health inequalities through their work with individual patients. However, greater variation was found when describing the boundaries of their role and how far these extended beyond individual encounters. Specifically, only those GPs fluent in discussing structural causes of health inequalities discussed obligations to change local systems via strengthening community linkages and to influence higher level policies related to the SDH. This suggests that while there is a degree of what Metzl and Hansen deem 'structural competency' amongst some GPs working in disadvantaged areas, the scope remains to deepen this competency more broadly. [ABSTRACT FROM AUTHOR]

The concept of vulnerability is frequently used in public health policies to develop tailored interventions or dedicate proportionately more resources to certain sub-populations. However, once segments of the population are identified as vulnerable, they are rarely consulted regarding whether this label is acceptable before instituting interventions. Instead, it is implicitly assumed that the targeted individuals identify themselves as vulnerable and experience an unambiguous and consistent need for public health assistance. In this paper, using public health interventions during heat waves as a case study, we question such assumptions. A qualitative study was conducted in Montreal, Canada involving two focus groups among populations specifically targeted by the heat action plan as vulnerable: one composed of individuals diagnosed with schizophrenia, and one composed of individuals who have alcohol or drug addictions. Findings revealed significant heterogeneity in the definition and experience of vulnerability as it is used in the context of a heat action plan in Montreal. We found differences between the two focus groups in several areas including sources of information they had access to within the heat action plan measures and their perspectives regarding the appropriateness of specific measures in the heat action plan. We then observed differences within each of the focus groups in several areas including their social networks relationships. The concept of vulnerability is often used in public health policies. Yet, while this concept may be convenient for shaping policies to reduce inequalities in health, the heterogeneity of populations defined as vulnerable should not be underestimated. [ABSTRACT FROM AUTHOR]

Global governance of non-communicable diseases (NCDs) has moved beyond the World Health Organization (WHO) to become a shared responsibility of WHO, the United Nations General Assembly, and other willing stakeholders. Despite the significant attention NCDs have received, progress towards global goals and political commitments remains disappointing. This lack of progress calls for greater attention to be given to how actions taken at the international level can lead to improvements in health at the country level. This paper reviews progress in the global response to NCDs by highlighting the role of pathways – both current and potential – for translating global aspirations into national actions that improve health outcomes. Important pathways to national action include the development of normative instruments, political accountability mechanisms, provision of economic support and technical assistance, and other forms of engagement we refer to as 'institutional pathways'. We find that global leadership on NCDs has focused predominantly on generating a suite of normative instruments for influencing national policy, together with global targets and reporting processes but with inadequate development assistance for NCDs, or investment in capacity building. We point to the distinctively legal and regulatory nature of many priority interventions identified by WHO for NCD prevention and control, arguing that legal capacity building of both government and civil society stakeholders is a vital, cost-effective yet neglected pathway for strengthening national responses. We outline a modest vision for global, regional and national leadership in capacity-building and in promoting the role for law in NCD prevention and control. [ABSTRACT FROM AUTHOR]

This paper addresses the relevance of medical folklore for vaccine policy intended to increase vaccination uptake. There are two primary claims of this paper: First, that dominant approaches to increasing US vaccination uptake have largely been based on deficient understandings of the root causes of anti-vaccination behavior; and second, that superior approaches to evidence-based policy must enlarge the scope of that evidence base to include crucial findings on belief formation, technical, and risk communication, and the folklore of vaccination. The failure to attend to this evidence results in interventions that are disconnected from the factors actually driving vaccination refusal. The paper describes the deficiencies in dominant approaches, and based on its analysis of the root causes of anti-vaccination behavior recommends superior evidence-based policies that emphasize upstream structural determinants of health behaviors. [ABSTRACT FROM AUTHOR]

This paper draws on the experiences of two researchers working to develop critical accounts of fatness with very different research participants – town planners and English Channel swimmers. Drawing across our encounters with these different participants, we explore the ‘doing’ of critical research through attending to the embodied encounters which take place in the ‘field’. In so doing, we reflect on moments where we have both, as part of the research encounter, not only found ourselves simply in fat-phobic contexts, but also effectively complicit in those contexts in our roles as interlocutors. In this paper, we explore the tensions inherent in those encounters for us (in all our multiple social, professional and embodied subjectivities), and ask what attending to these embodied confrontations (or the avoidance of confrontation) might mean for the critical research process – both in terms of the impact on practice and outputs of research for individual researchers and the participants with whom they are working. In doing so, we focus on what attention to the research encounter adds to debates about ‘impact’ in social science, about the doing of scholar-activism and about the role of the researcher’s body in the research encounter. [ABSTRACT FROM PUBLISHER]

Civil society engagement around health care and population health improvement is an important driver towards Health for All. Research can improve the effectiveness of health activism by examining the resources, structures and strategies of civil society engagement. However, research to support such engagement faces epistemological and methodological challenges which call for specific research strategies. A four year multi-country study was undertaken by the People's Health Movement, a global network working for health for all. The research took place in six countries (Brazil, Colombia, DR Congo, India, Italy, South Africa) and globally, and was directed to understanding five domains of civil society engagement: movement building; campaigning and advocacy; capacity building; knowledge generation, access and use; and engaging with governance. The research plan and methods of data collection and analysis were tailored to address the objective of improving activist practice, while negotiating research challenges identified during the design phase. Results include insights into the practice of civil society engagement in relation to the five domains of activist practice, as well as experience gained in managing six methodological challenges which we describe as: making meaning, aligning research and action, managing power relations, valuing experiential knowledges, chaos and contingency, challenging preconceptions. Researching activism can produce useful insights into practice as well as support continuous improvement in the effectiveness of such activism. However, there are significant methodological challenges that can be addressed through appropriate strategies. More research, building on the approach described in this paper, can contribute to more effective civil society activism for health. [ABSTRACT FROM AUTHOR]

Intersectionality is increasingly adopted in research to understand the complex ways that social inequalities shape health. Intersectional research thus explores how multiple forms of oppression intersect and shape how marginalised social groups experience health issues. Yet intersectionality research has often neglected to focus on the upstream structural factors that (re)produce social inequalities in health. In this paper, we argue that intersectionality can further advance social inequality in health research when it is used to understand more than just the multiplicity of socially marginalised groups' experiences and identities, but also how interlocking social structures and power relations perpetuate social inequalities in health. We suggest that analysing policy with an intersectional lens is a key entry point to empirically explicate the underlying mechanisms that permit social inequalities in health to persist. To illustrate our argument, we use the example of how an intersectional perspective can be adopted to better understand the role of tobacco control policies in contributing to social inequalities in smoking. [ABSTRACT FROM AUTHOR]

The author discusses the public character of public health in Africa. He discusses public health provisioning in sub-Saharan Africa, the role of non-governmental organizations in efforts to democratize African civil society, the renewed calls for commitment to universal health coverage and the parameters of community collaboration in medical research, social accountability in health service delivery and public engagement with health interventions.

Global risks of zoonotic disease are high on policy agendas. Increasingly, Africa is seen as a ‘hotspot’, with likely disease spillovers from animals to humans. This paper explores the social dynamics of disease exposure, demonstrating how risks are not generalised, but are related to occupation, gender, class and other dimensions of social difference. Through case studies of Lassa Fever in Sierra Leone, Henipah virus in Ghana, Rift Valley Fever in Kenya and Trypanosomiasis in Zimbabwe, the paper proposes a social difference space–time framework to assist the understanding of and response to zoonotic diseases within a ‘One Health’ approach. [ABSTRACT FROM PUBLISHER]

Trade agreements influence the distribution of money, goods, services and daily living conditions – the social determinants of health and health equity, which ultimately impacts differentially on health within and between countries. In order to advance health equity as a trade policy goal, greater understanding is needed of how different actors frame their interests in order to shape government priorities, thus helping to identify competing agendas across policy communities. This paper reports on a study of how policy actors framed their interests for the Trans Pacific Partnership agreement. We analysed 88 submissions made by industry actors, not for profit organisations, unions, researchers and individual citizens to the Australian government during treaty negotiations. We show that policy actors' ideas of the purpose of trade agreements are shaped by competing underlying assumptions of the role of the state, market and society. We identify three primary framings: a dominant neoliberal market frame, and counter frames for the public interest and state sovereignty. Our analysis highlights the potential enabling and constraining impact of policy frames for health equity. In particular, the current dominant market framing largely excludes the social determinants of health and health equity. We argue that advocacy needs to tackle head on the underlying assumptions of market framings in order to open up space for the social. We identify successful examples of health framing for equity as well as opportunities for engagement with 'non-traditional' allies on shared issues of concern. [ABSTRACT FROM AUTHOR]

Noncommunicable diseases (NCDs) kill 40 million people each year and are the cause of 70% of global deaths annually. Proximal risk factors include tobacco use, physical inactivity, the harmful use of alcohol and consumption of unhealthy food, which are shaped by the social and economic conditions of daily life, known as the social and commercial determinants of health. It is well recognised within the global health community that policy coherence across all levels of government at the national and international level is required to address NCDs. To date, however, there has been little coherence between health and trade policy, which directly affects access to unhealthy or healthy commodities. This paper explores policy actors' views of the challenges in achieving coordinated and coherent NCD policy across health and trade sectors. Drawing on interviews (n = 18) with key policy actors and using a policy framework that focuses on ideas, power and the 'deep core' of neoliberalism, we identify the role of competing frames, power asymmetries and interests in constraining policy coherence. We also find differences between NCD risk factor domains. Tobacco control was highlighted as one area of generally successful coherence internationally. In contrast, alcohol and nutrition were identified as areas with little coherence. Industry power, the role of evidence, presence of absence of a treaty, the extent of coordinated advocacy and leadership by intergovernmental organisations were key factors influencing coherence. In light of these constraints, the role of advocacy by non-governmental organisations was highlighted as the key for much-needed policy change. [ABSTRACT FROM AUTHOR]

Core HIA documents, researchers and practitioners assert the significance of community participation in health impact assessment. Despite the rhetoric, there has been little critical examination of the role of community participation in HIA. Knowledge and debate regarding what constitutes community participation and how it may best be achieved is often confused and opinion is divided as to its usefulness and appropriateness for HIA. This paper does not seek to argue the merits or drawbacks of community participation; rather, the authors explore the origins and character of the current discord around public participation in HIA and provide a lexicon for moving practice and discussion forward. The authors argue that the origins of the participation problem stem from: (1) unexplored tensions within the Gothenburg consensus paper and other formative documents in the development of HIA; (2) inherent tensions arising from the dual origins of HIA, specifically Environmental Impact Assessment (EIA) and Healthy Public Policy (HPP); and (3) a lack of rigour and clarity relating to the terminology of community participation where community participation is used as a 'catch all' phrase for every situation without critical examination. In order to move debate forward, the authors advance a model, the Typology of Public Involvement in HIA, for guiding discussion of community participation. This model comprises a set of context-specific HIA approaches with varying degrees of public involvement. The model also presents a suite of defined terms for understanding and discussing participation. [ABSTRACT FROM AUTHOR]

This paper analyses the newly proposed United Kingdom (UK) psychiatric diagnosis of ‘dangerous and severe personality disorder’ (‘DSPD’). The aim is to show how the category of ‘DSPD’ manifests aspects of Beck's analysis of the ‘risk society’ and poststructural ‘governmentality’ approaches to understanding the notion of risk. Concepts such as ‘dangerousness’, ‘violence’ and ‘risk’ are critically reviewed in relation to ‘DSPD’ and are found to be less than objective. The paper interrogates the political underpinnings of this newly proposed diagnosis and analyses pre-existing frameworks of potential utility for developing further understanding of dangerousness and violent behaviour. Key issues are critically discussed in relation to the concept of ‘dangerousness’ including the reliability of assessment tools, the socioeconomic status of those potentially diagnosed with DSPD and detention without committing any prior offence. The paper also discusses the potential for conflict between the proposed legislation, the UK Human Rights Act 1998, healthcare practice and the likelihood of divided professional loyalties. The paper argues that this newly proposed public health policy has a sociopolitical rather than psychiatric rationale for justifying psychiatric detention and, as such, is a psychiatric manifestation of the late modern culture of risk. [ABSTRACT FROM AUTHOR]

Comments on various issues concerning public health in Great Britain. Challenges in building multidisciplinary public health; Concerns over health policy agendas in Great Britain; Significance of partnership for making public health to work effectively within current structures.

User involvement has become a central tenet of government policy regarding health and social care. Likewise, the role of 'evidence' is seen as being at the heart of effective planning and delivery of health services (Our Healthier Nation, 1999). This paper examines the role of user involvement in evaluative research within the provision of an evidence base related to practice development. By focusing on the role of participatory research in the creation of an evidence base for healthcare provision, the authors explore the nature and possibilities of user involvement in providing an evidence base within a community mental health service. The paper identifies factors that may facilitate or inhibit user involvement and participation in evaluative research. It is argued that whilst the effective involvement of users may improve the quality and validity of research evidence, user participation in the research process is both contextual and contingent. For users to participate in the research process in a meaningful way requires changes in the way that research is commissioned and assessed so that the nature of user involvement may become viable. The authors suggest that the creation of evidence in health research is shaped by the social relations of the research process as well as by the methodologies used. [ABSTRACT FROM AUTHOR]

The aim of this paper is to discuss the ways in which the setting approach to health promotion in schools, as part of knowledge-based international policies and guidelines, is embedded in the Danish policy landscape and enacted at the local governance level. The study draws on the sociology of translation and treats policy implementation as a non-linear process of (re)interpretation involving different actors in plural, mutually interwoven, non-hierarchical networks. Data were generated and analysed using a three-tiered process: the first tier focused on key international guidelines, the second on national policies, and the third on policies in selected municipalities. Through these tiers, we discuss actors and actor networks involved in the translation processes, their interactions and the dynamics of problematisation at the national and local levels. The results point to two different, but entangled, processes of translation. At the national level, despite resistance by a number of actors with differing priorities, the translation resulted in the integration of selected key principles of the setting approach to health promotion in the national curriculum for health education. At the municipal level, however, the principles seem to be 'lost in translation', as the treatment of schools as settings for promoting health and well-being remains largely subordinate to the discourses of disease prevention and individual behaviour regulation, dominated by the agenda of actors in the health sector. [ABSTRACT FROM AUTHOR]

Research suggests that food insecurity exacerbates the harms experienced by people who use drugs (PWUD). Therefore, improving the food security status can help PWUD reduce drug-related harms. This paper identifies a knowledge gap in public health and harm reduction literatures regarding the relationship between food and harm reduction. We argue that there needs to be a more comprehensive and systematic model of food provision in harm reduction services. Our argument is based on a qualitative case study of 42 people who currently use, or have used drugs in Vancouver, Canada and of staff of 27 programs that provide harm reduction services in the city. The research demonstrates how PWUD experience the effects of drug use on their food consumption, how they access food, and how they practice self-care. It also shows how harm reduction services, while they often provide food, are unable to systematically address the dietary-related harms associated with drug use. This presents an opportunity and a challenge for these organizations and for harm reduction as a public health approach. We call for more research to be done on food as harm reduction and for stable publically funded food provision in harm reduction-oriented services. [ABSTRACT FROM AUTHOR]

Public health efforts to lift childhood vaccination rates can be supported or undermined by media representations of parents. Polarising representations neglect the large range of ‘middle-ground’ positions people occupy, potentially alienating parents. In recent years, Australian public health actors have tried to better engage journalists to avoid this. As these efforts have unfolded, the main national immunisation policy lever has become more punitive. This paper examines whether Australian newspaper representations of parents have changed, by comparing 153 newspaper articles from two periods: 1997-1998 (prior to the development of a public health lobby targeting the media; when the first national childhood immunisation policy was introduced) and; 2015-2016 (5 years after advocacy groups began working with the media; and when the national policy took a punitive turn). We analyse patterns and shifts (between 1997-1998 and 2015-2016) in the portrayal of parents as complacent, alternative, hesitant and as choosing. Australian newspaper portrayals of parents are broadly aligned with the policy targets of the day. In 2015-2016, there was less negative representation of parents who occupy the ‘middle-ground’ between vaccine acceptance and rejection. However, coverage of alternative parents (vaccine objectors) intensified in quantity and negativity. Concurrently, there were new (minority) portrayals of vaccine objectors as invisible, and as victims being denied choice. This signals that reporting may simultaneously align with national policy targets and destabilise public health efforts to avoid polarising misrepresentations of parents, characterisations likely to undermine trust in public health. Rather than ‘blame the media’, this analysis illuminates conflicts within public health. [ABSTRACT FROM AUTHOR]

Much public health research considers interventions that influence and are influenced by both individuals’ health and the society around them; this can be described as a complex system. We consider the role of explanation alongside statistical inference as crucial to obtaining credible and useful insights, particularly in light of concerns about a ‘crisis of replication’, and reflect on the difficulty in researching complex systems. In this paper, we make a connection with Lipton’s philosophy of inference to the best explanation, and offer some tentative practical recommendations, extending suggestions from different fields. An extended hypothetical example is given on introducing ‘sugar tax’ in England. [ABSTRACT FROM PUBLISHER]

An introduction is presented in which the editor discusses articles in the issue on topics including how issues such as trust in government shape responses to contact tracing, the policy responses to COVID-19 that have exacerbated social divisions and undermined social justice and the ethnic inequalities in exposure to risk among health works in the British National Health Service (NHS).

The aim of this paper is to consider 'New' Labour's socio-economic and health policies, discuss how they influence preventive health strategies aimed at men, and identify the implications for managers, researchers and practitioners working to improve public health in the primary care sector in England. Policy, theoretical work and empirical research are analysed, critically, to develop the arguments in the paper. Although men may be perceived as a 'hard to reach group', insufficient consideration has been given to how health policy facilitates or restricts successful preventive health work with men. The 'gender duty', which has recently been introduced in England, presents an opportunity to build on earlier successful public health work with men. There is some evidence that innovative public health strategies, informed by an understanding of gender, with men are being developed. This may enable primary care trusts to more successfully, and creatively, target and engage men in health improvement activities. However, the current dominant ideology in public health policy in England is grounded in a perspective that emphasises biomedical, neo-liberal and psychological explanations of health and which neglects the relationship between gender and health inequalities. Recognition of the links between gender, poverty, and the concomitant inequalities, is a priority when planning preventive health work with men. If such inequalities are to be redressed, social and economic policies underpinned by values of equity and social justice are needed, incorporating a more nuanced understanding of the role of gender in health. [ABSTRACT FROM AUTHOR]

This paper critically examines the public policy environment that underpins the politics of health promotion in England. English health policy from the late 1970s to the mid 1990s was not receptive to health promotion. The new Labour government elected in 1997 claimed to embrace a 'Third Way' between the free market and socialism that would appear to embrace a community-centred approach to health promotion that would through partnership-building promote equity; perversely, however, the election of this government rhetorically committed to healthy public policy was accompanied by a crisis in health promotion delivery. Despite apparent commonalities between the Third Way and health promotion, the Third Way was in many respects a neoliberal ideology and so has contributed to the marginalisation of health promotion. Although some might argue that health promotion has been mainstreamed, it is argued here that in terms of the crucial National Health Service infrastructure underpinning the health promotion movement, that the organisational capacity for health promotion has been significantly weakened. Thus the question is how you revive a movement that has lost its way? The answer must include taking a historically informed approach to analysing the problem and identifying solutions. Wider systems issues in England include the emergence of multidisciplinary public health, the sequence of changes to national health promotion organisations and the wider marginalisation of the public health movement. It is only by critically analysing and addressing these systemic issues that the prospects for health promotion in England can be revived. [ABSTRACT FROM AUTHOR]

This paper examines the power of a measure of drug dependence to predict future changes in drug consumption and related outcomes such as criminality and homelessness. Data from an ongoing, longitudinal, interview study (DORIS) of 1033 new attenders at a range of Scottish drug treatment facilities were analysed, 16 months on from sample recruitment, using forward stepwise logistic regression models. Dependence was measured at baseline and in subsequent interview sweeps using the five-item Severity of Dependence Scale (SDS). In addition to drug consumption measures, a range of non-drug consumption measures were used, including those measuring housing status, employment status and criminality. Respondents' SDS scores fell significantly over time, and SDS score at 16 months was a significant independent predictor of outcome measures such as reports of acquisitive crimes. However, SDS score at baseline was not an independent predictor of either drug consumption measures at 16 months or non-drug outcomes such as criminality at 16 months. Treatment services are increasingly designed to view drug use as a chronic condition, with dependence as its core property. However, while SDS score functions as a useful outcome measure, puzzlingly, severity of dependence does not predict future drug using careers in these data, the largest longitudinal cohort of Scottish drug users ever studied. Accordingly, the implications of these findings for the conceptualisation of drug use and for services planning and delivery are both unsettling and unclear. [ABSTRACT FROM AUTHOR]

This paper explores recent developments in prison public health, recommending that future prison health policies and practices become more 'upstream' in their outlook and approach. It is argued that this will require much firmer acknowledgement of the significance of broad, systemic and structural determinants of prisoner health, particularly if the World Health organization's vision for a 'healthy prison' is to be realized. Epidemiological evidence plainly shows that prisoners have experienced - and continue to experience - worse health than the general population, despite the fact that prison settings across the European Union have been targeted for health promotion by the World Health Organization since 1994. In 2005, WHO launched a new 10-year prison public health plan, which it envisages will begin to address key prison health determinants. In the UK, New Labour has identified prison health as a key public health objective within Choosing Health, although health interventions within prisons continue to be predominantly geared towards efficient and effective primary and secondary healthcare, and much less towards public health goals. This paper strives to open up the debate on prison public health, advocating a progressive and more sustainable approach to developing and commissioning health services for prisoners. [ABSTRACT FROM AUTHOR]

This paper applies Jessop's analysis of the new political economy of welfare to the case of the NHS, exploring the insights into the changes in health policy in the UK that such a perspective offers. Alongside Jessop's analysis, the paper also considers the competing tension of path dependency in health policy, and the possibility of alternative futures to those envisaged in Jessop's model. [ABSTRACT FROM AUTHOR]

Building an evidence base to underpin policy and practice in health and social care is one of the cornerstones of New Labour's modernization programme. However, the history of evaluation research in Britain and America suggests that this enterprise may be thwarted as much by politics as by methodological debates. The 'paradigm wars' that characterize the social sciences also feature in the field of evaluation research, and changes in the way 'health' is conceptualized in the 'new public health' have intensified debates about approaches to evaluation and what counts as evidence. Health Action Zones have been vaunted as both the 'flagships' of the government's health policy and as 'learning initiatives'. This paper uses the example of Health Action Zones to discuss the use of a theory-based approach to evaluation for the purpose of generating the policy learning needed to tackle health inequalities, drawing on experience in Plymouth. The limitations of the 'traditional' approach to evaluation are examined, along with recent guidance from the Medical Research Council about evaluating complex community initiatives. It is argued that the case for theory-based evaluation extends beyond criticism of the traditional approach to develop evaluation theory and practice from the perspective of critical realism. This approach to evaluation seeks explanation and understanding about how and why projects 'work' or not in specific contexts, rather than pragmatic solutions to de-contextualized problems. The paper concludes by reflecting on the politics of evaluation in the field of health and social care, calling into question the government's commitment to evidence-based policy and practice. [ABSTRACT FROM AUTHOR]

A growing number of countries are beginning to move from acknowledging the existence of health inequalities to developing policies to reduce them. Many of these policies consist of complex interventions, operating at a number of levels, which aim to make a positive contribution to health improvement in deprived communities. Evaluating the efficacy of such initiatives poses particular challenges for evaluation. This paper argues that there is real potential in applying a theory-based approach to the evaluation of complex community-based initiatives. Using practical examples from the national evaluation of Health Action Zones in England, the paper outlines the key components of such an approach and argues that theory-based evaluation can strengthen programme design and implementation, as well as promote policy and practice learning about the most effective interventions for health improvement. We conclude that sophisticated theory building social change mechanisms in community settings is essential if real learning is to be generated from concerted efforts to achieve social change. [ABSTRACT FROM AUTHOR]

In relation to clinical trials, it is far more usual to speak of the community (singular, static) than of publics (multiple, emergent). Rarely defined, the community is commonly taken to be the existing people in a given area, which the trial will engage, mobilise or sensitise to facilitate successful recruitment and retention. Communities are assumed to pre-exist the research, to be timeless, and to be a whole (sometimes consisting of different parts, referred to as stakeholder groups). In this paper, we suggest a conceptual shift from ‘trial community’ to ‘experimental publics’. Using an empirical case study of an HIV prevention trial in Zambia, we draw out the following key points: firstly, publics do not pre-exist research activities but are enacted in concert with them. Secondly, publics are dynamic and transient. And thirdly, experimental publics are situated at the intersection of various forms of inclusion and exclusion, both locally and globally. Our findings emphasise the need to create long-term forms of participation in science, which transcend both the instrumental goals and the individual timelines of specific trials. [ABSTRACT FROM PUBLISHER]

This paper reconsiders the Ebola response in the US as a panic that was both predictable and problematic. Public health professionals and policy-makers have historically drawn attention to and prepared for emerging infectious diseases by raising the specter of catastrophe, generating fears that the media and politicians are often willing to amplify. Although this approach can increase awareness of and funding for global health threats, it also sows the seeds of panic, stigmatizing people associated with the disease, and compromising an effective, evidence-based response. We offer lessons for public health leaders as they review the US Ebola response in order to prepare more responsibly for future disease scares such as that posed by the Zika virus. [ABSTRACT FROM PUBLISHER]

This qualitative study explores the structural barriers to preventive interventions targeting childhood obesity in the Danish health care system. Based on interviews with relevant health care professionals, the paper reports on the problems which are experienced by general practitioners and health visitors and which complicate implementation of the policies of the Danish health authorities. Findings show that the current system is not well equipped to treat early overweight. A gap in primary preventive health care for children at age 3–5, indistinct lines of responsibility, inadequate cooperation, and lack of resources together make it difficult for health care professionals to initiate interventions and reach the children in need of support. By analyzing the policy implementation process in a theoretical framework that discloses the discursive allocation of responsibilities, the study is able to provide a deeper description and analysis of the problem. The study makes it clear how preventive health care for overweight children rests on the negotiation of formal and performed responsibilities among health practitioners within a framework of scarce resources and communication deficit. [ABSTRACT FROM PUBLISHER]

HIV and hepatitis B and C are viruses that have been unduly set apart from other infectious diseases in terms of the symbolic pull they exert and the anxiety they produce. This is reflected in health care policy and protocol. Hospitals, health care regions and colleges of physicians and surgeons create guidelines and procedures that single out HIV or hepatitis B and C as requiring special attention. This paper examines such surveillance and stigma in blood-borne pathogen protocol, using the example of recently refined policies in Newfoundland, Canada. We argue that policies distinguishing HIV and hepatitis B and C as requiring special treatment are produced by a combination of four factors: (1) the ideological and political function of risk discourse, and how this overshadows actual measures of probability, (2) the historical association of HIV and hepatitis B and C as belonging to 'deviant' bodies, (3) the normalizing function of health surveillance mechanisms and (4) the contradictory image of the 'sick' doctor. It is crucial that health professionals be critical of bylaws that single out HIV and hepatitis B and C as these guidelines are unjust and may impede efforts to control the disease. [ABSTRACT FROM AUTHOR]