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Child and maternal health, a key marker of overall health system performance, is a policy priority area by the World Health Organization and the United Nations, including the Sustainable Development Goals. Previous realist work has linked child and maternal health outcomes to globalization, political tradition, and the welfare state. It is important to explore the role of other key policy-related factors. This paper presents a realist synthesis, categorising policy instruments according to the established NATO model, to develop an explanatory model of how policy instruments impact child and maternal health outcomes. A systematic literature search was conducted to identify studies assessing the relationships between policy instruments and child and maternal health outcomes. Data were analysed using a realist framework. The first stage of the realist analysis process was to generate micro-theoretical initial programme theories for use in the theory adjudication process. Proposed theories were then adjudicated iteratively to produce a set of final programme theories. From a total of 43,415 unique records, 632 records proceeded to full-text screening and 138 papers were included in the review. Evidence from 132 studies was available to address this research question. Studies were published from 1995 to 2021; 76% assessed a single country, and 81% analysed data at the ecological level. Eighty-eight initial candidate programme theories were generated. Following theory adjudication, five final programme theories were supported. According to the NATO model, these were related to treasure, organisation, authority-treasure, and treasure-organisation instrument types. This paper presents a realist synthesis to develop an explanatory model of how policy instruments impact child and maternal health outcomes from a large, systematically identified international body of evidence. Five final programme theories were supported, showing how policy instruments play an important yet context-dependent role in influencing child and maternal health outcomes. • A realist synthesis was conducted. • Assessed relationship between policy instruments and child and maternal health. • Synthesis informed by 132 unique studies. • Five final programme theories were supported. • Impact of policy instruments was context-dependent. [ABSTRACT FROM AUTHOR]

There is a critical shortage of health professionals globally which is affecting the possibility of attaining universal health coverage. Developing countries in sub-Saharan Africa such as Ghana and Nigeria are disproportionately affected and the shortfall in health professionals is envisaged to worsen over the next decade. Countries have responded differently in addressing this shortage. To understand the differing response to the same policy issue in two countries that share similar characteristics in terms of geolocation, socioeconomic indices and disease burden, this paper offers a comparative policy analysis of the two countries using the 3-I framework and punctuated equilibrium theory as comparative policy analysis tools. The analysis identified the ideas, interests, and institutions at play and how they have led to different policy outcomes in both countries. The analysis also shows the interaction between subsystems, policy images and policy venues and how this interaction led to policy change, in the case of Ghana and lag in the case of Nigeria. Our findings show four critical areas in addressing health workforce shortages in both countries – a general approach to addressing the issue, welfare and remuneration, workforce autonomy and career progression, and financing for workforce improvement. For Ghana, there has been significant policy change including implementing strategies for increasing the production of health professionals and addressing remuneration and welfare issues. For Nigeria, there has been seems to be a lag in policy change. While the findings show that Ghana's approach has seemingly put them on a good path toward universal health coverage, applying any lessons should, however, be contextual, considering other country-level and health systems factors that are relevant to addressing health workforce shortages. • African countries bear the disproportionate burden of global health worker shortage. • Different countries in the region have had different policy responses to the issue. • Ghana's response has been strategic, positive, and leading them towards UHC. • Nigeria has witnessed policy stagnancy, encumbered by health systems politics. • To achieve UHC, health worker shortages need strategic context-based policy solutions. [ABSTRACT FROM AUTHOR]

This paper investigates how restriction policies have impacted elderly self-assessed health (SAH) in Europe during the pandemic, and how the Covid-19 infection interacts with policy stringency to modulate the SAH deterioration. Using the Survey of Health, Aging and Retirement in Europe (SHARE) between October 2019 and August 2021, including 9,034 adults aged 50 years and above, alongside with a stringency index from the Oxford's Coronavirus Government Response Tracker (OxCGRT), we design both an adjusted probit model and a recursive bivariate probit model to test for endogeneity of Covid-19 infection. Estimations results show a bell curve between stringency and SAH degradation: a deleterious effect of restrictions at low levels of stringency up to a tipping point after which more stringent policies become protective. Covid-19 infection moderates this association. Depending on individuals' initial health, the effect of restrictions is uneven: highly stringent policies become damaging for individuals most likely to enter a vulnerabilization path, for whom the bell curve is thus inverted. Overall, this study shows clear patterns of association between policy stringency and perceived health among older Europeans, and highlights the potential trade-off between targeting as many people as possible, those in poor health or those on the edge of vulnerability. • The association between policy stringency and SAH degradation is a bell curve. • Strict restrictions only affect the SAH of people likely to become vulnerable. • Covid-19 infection moderates the deterioration of SAH caused by policy stringency. • The recursive bivariate probit model controls for endogeneity in infection. [ABSTRACT FROM AUTHOR]

In 2011, China implemented tougher driving-under-the-influence laws, which criminalized driving under the influence of alcohol for the first time and increased penalties. This paper provides the first comprehensive analysis of the effects of stricter drinking policies on men's smoking behavior by using data from the 2010 and 2012 waves of the China Family Panel Studies. The results show that stricter drinking policies reduced smoking initiation and the number of cigarettes smoked per day among men by reducing the frequency and quantity of alcohol consumption. Heterogeneity analyses show that the impact of the policy is more pronounced not only for men aged 41–55, but also for men who have higher educational qualifications, who are employed, or who are not members of the Communist Party. • Tougher driving-under-the-influence laws subject offenders to more severe penalties. • Stricter drinking policy affects men's smoking behavior. • Stricter drinking policy reduces frequency and quantity of alcohol consumption of men. • Policy effect is stronger for men aged 41–55, educated, employed, or party-affiliated. [ABSTRACT FROM AUTHOR]

For this paper, I conducted an interdisciplinary qualitative study to investigate transgender experiences accessing gender-affirming healthcare (GAH) in Egypt. I outline how the current health policy on GAH was developed and its negative impact, celebrating the resilience of transgender people in navigating the hostile anti-transgender environment, and conclude by offering some health policy recommendations to improve the GAH situation. Since 2003, Egypt has introduced an Islamic Sharia-influenced policy that banned accessing GAH for transgender people, placing professional and legal liability on healthcare providers. The policy created an anti-transgender medical environment, forcing transgender people to rely on Do-It-Yourself GAH or underground, risky, ill-equipped, and overpriced medical facilities. Other non-medical factors also impacted transgender people's ability to access GAH: social stigma, family rejection, state persecution, and economic insecurity. Despite this multilayered anti-transgender environment, transgender people proved to be innovative and resilient, creating ways to overcome these challenges and continue to exist. Transgender people created communal spaces online to guide each other in navigating the challenges of accessing GAH and used various means to challenge bans on GAH. Egypt, Gender-Affirming Health Care, Islam, Policy, DIY, Transgender, Law. • Egypt's current health policy bans gender-affirming health care for transgender people. • The health policy pushed transgender people into do-it-yourself hormone therapy and underground medical clinics. • Some challenges accessing GAH include financial instability, social stigma, state prosecution, and lack of GAH services. • Transgender people proved innovative and resilient as they mitigated these challenges by relying on communal support. • New possible avenues for reforming the current policy, such as strategic litigation, are being explored. [ABSTRACT FROM AUTHOR]

Multilevel analysis of individual heterogeneity and discriminatory accuracy (MAIHDA) is a new approach to quantitative intersectional modelling. Along with an outcome of interest, MAIHDA entails the use of two sets of independent variables. These include group demographics such as race, gender, and poverty status as well as strata which are constructs such as Black female poor, Black female wealthy, and White female poor. These constructs represent the combination of the demographic variables. To operationalize the approach, an initial random intercepts model with strata as a level 2 context is specified. Then, another model is specified that includes the strata as well as the demographic variables as level 1 fixed effects. As such, it is argued that MAIHDA uniquely identifies the additive and intersectional effects for any given outcome. In this paper we show that MAIHDA falls short of this promise: the strata are an individual-level composite variable not a level 2 context. Rather than being analogous to neighborhoods as contexts, strata are analogous to socio-economic status which is a combination of individual-level demographic variables, albeit often presented as a group-level characteristic. The result is that the demographic variables are inserted in both level 2 and 1. This duplication across the levels in MAIHDA means that there is a built-in collinearity across the levels and that the models are mis-specified and, therefore, redundant. We conclude that single-level models with the demographic variables and interactions or with the strata as fixed effects are still the more accurate models for quantitative intersectional analyses. • There has been limited analysis of the MAIHDA method. • We compare MAIHDA to traditional HLM. • We show that strata are a level 1 composite variable not a level 2 context. • We identify duplication and collinearity in this approach. • We advocate for single level models in quantitative intersectionality. [ABSTRACT FROM AUTHOR]

Globally, as medical and mental health associations increasingly have expressed support for the gender-affirming care model for trans and gender expansive youth, this model has been paradoxically banned across the United States. Ban proponents have deemed the science behind gender-affirming care to be dangerously uncertain. Examining the first gender-affirming care ban for minors, Arkansas's Save Adolescents from Experimentation (SAFE) Act of 2021, we addressed the following two questions: 1) who are the scientists, clinicians, and political organizations that promote SAFE and similar bans?; and 2) what are the scientific arguments they make to defend SAFE in federal court? First, we developed a typology of the various "agents of scientific uncertainty" behind these bans, drawing on literature from the sociology and history of science and medicine as well as the political economy of scientific doubt. Second, we created and qualitatively analyzed a dataset featuring 375 unique citations referenced throughout federal litigation over SAFE to identify these agents of scientific uncertainty's arguments. We sorted these arguments into eight categories, which reveal how agents distorted scientific evidence and exaggerated real uncertainties and risks in gender-affirming care. This case study establishes a frame for understanding the growing prevalence and legal impact of scientific arguments against gender-affirming care. • Gender-affirming care (GAC) for minors has been increasingly banned in the U.S. • Despite growing medical support, ban proponents label GAC dangerously uncertain. • The paper outlines the scientists, clinicians, and political groups defending bans. • It also describes the scientific arguments used in litigation defending bans. • Scientific uncertainty arguments have been successful at unduly restricting GAC. [ABSTRACT FROM AUTHOR]

The British National Health Service (NHS) relies for the great bulk of its funding on direct taxation, but the contribution of charitable sources of income to the NHS is not well-understood. The few studies of charitable giving to the NHS to date have concentrated on aggregate levels of income and expenditure. However, to date there has been limited collective understanding about the extent to which different kinds of NHS Trusts benefit from charitable funding and about the persistence of inequalities between trusts in their access to these resources. This paper presents novel analyses of the distribution of NHS Trusts in terms of the proportion of their income that comes from charitable sources. We build a unique linked longitudinal dataset which follows through time the population of NHS Trusts, and the population of associated NHS charities, in England since 2000. The analysis illustrates intermediate levels of charitable support for acute hospital trusts compared with the much lower levels of charitable support for ambulance, community and mental health Trusts and, conversely, much higher levels of charitable support for Trusts providing specialist care. These results represent rare quantitative evidence relevant to theoretical discussions about the uneven nature of the voluntary sector's response to healthcare need. They provide important evidence for a key feature (and arguably weakness) of voluntary initiative, namely philanthropic particularism - the tendency for charitable support to focus on a restricted range of causes. We also show that this 'philanthropic particularism' – reflected in the very sizeable differences in charitable income between different sectors of NHS trusts - is becoming more marked over time, while spatial disparities, notably between elite institutions in London and other locations, are also substantial. The paper reflects on the implications of these inequalities for policy and planning within a public health care system. • Novel analyses of pattern of charitable resources supporting NHS Trusts in England. • Trust – level comparisons of the ratio of charitable income to total Trust income. • Lower levels of fundraising for ambulance, community and mental health Trusts. • Higher levels of charitable support for larger Trusts and Trusts in London. • Charitable income of specialist Trusts has grown; other Trusts have seen decline. [ABSTRACT FROM AUTHOR]

The substantial gap in electoral participation between upper and lower socioeconomic status (SES) groups has long been a vexing problem for modern democracies and one that demands explanation. Following separate bodies of scholarship that suggest (1) socioeconomic disadvantage diminishes health and (2) poor health demobilizes eligible voters, this paper proposes that health serves as a pathway through which social inequality manifests in disparities in electoral participation. This paper tests this hypothesis by analyzing U.S. presidential election data, in which structural equation modeling was used to decompose the association between SES and turnout, through health. Results show that health mediates approximately 20% of the relationship between SES and electoral participation. These findings imply a political explanation for the endurance of population health disparities; they may self-sustain by disproportionately limiting the political voice of the disadvantaged, for whom more egalitarian social and health policy would be most beneficial. • Individuals of low socioeconomic status vote at lower rates and are in worse health. • Individuals in poor health vote at lower rates. • Health explains roughly 20% of the association between social status and voting. • Health disparities may endure by reducing participation of the disadvantaged. [ABSTRACT FROM AUTHOR]

We look at Universal Health Coverage (UHC) through a historical investigation of the "health for all by 2000" policy adopted by the WHO in 1978. Within contemporary debates on access to care, Alma Ata is usually considered as a brief moment of well-intentioned utopia, which buckled to global health's agenda of performance metrics and targeted diseases. Such visions of primary health care (PHC) are shared references in the debates about UHC. Aiming at a less geopolitical and more local approach of the strategy's roots than the existing historiography, the paper draws from historical and ethnographic work on health policies and practices in Tanzania, Oman and Kerala (India), in which PHC was not only envisioned, but constructed as the backbone of local health systems, often prior to Alma Ata. All three states were praised for their PHC achievements. Studying them allows for emphasizing the importance of national trajectories in PHC, as well as revealing shared core issues such as the importance of access and affordability, of the focus on rural centers and the mass training of non-medical personnel, and of the articulation of vertical programs and horizontal system building. It also reveals very different trajectories in terms of duration, priorities, outcomes and international visibility. • The paper is a comparative study of PHC development in Tanzania, Oman and Kerala. • History shows that health systems had contingent relations to Alma Ata policy. • WHO's 1978 primary health care strategy is a retrospective utopia in debates on UHC. [ABSTRACT FROM AUTHOR]

Instead of diminishing with the spectacular advancement of medical expertise in the country , unqualified biomedical practice in India has been strengthened by the growth of the pharmaceutical production in the twenty first century. In public health discourse, the view that the informal health practitioners have to be punished and abolished has been countered by the recommendation that they could be trained and incorporated in primary health care where public health amenities are inadequate. The quality of care provided by the informal health care practitioners has also been subject to clinical assessment based on standardized patient vignettes. Based on a sociological approach, this paper examines the time line of chronically ill patients under lived conditions to arrive at an understanding of the role of informal health practitioners in long term treatment and highlights the setbacks. This paper draws on 253 household surveys from two villages in Madhya Pradesh, in depth interviews with four unqualified practitioners in the area, twenty five unstructured interviews of chronic patients, twenty five structured interviews on the cases of untimely death and FGDs with health workers in 2021. Informal health care practitioners offer consultation cum dispensing of medicines and are the primary source of biomedical care in the remote study area without any public transport. But they are 'for profit' economic actors who are ill-equipped to handle chronic diseases. What sets them aside from the qualified private doctors in the town is their social obligation to balance their profit motive with the ethics of proximity and neighborly ties with the villagers amidst whom they reside. These features of the market and community place the informal health care practitioners at the cusp of economy and society and defy simple binaries that they are either crooks or assets. • Unqualified health practitioners provide medical care in India where none is available. • Assessing their practices, clientele and exact role is crucial to health care policy. • One point standardized patient vignettes are used to assess their quality of care. • Their treatment of chronically and severely ill patients over time also has to be examined. • They are 'for profit' economic actors, but embedded in the community. [ABSTRACT FROM AUTHOR]

Medical education programs profess commitments to justice, equity, and inclusion, seeking to diversify the profession and better serve patient populations. Although disability has more recently joined recognized categories of valued diversity, significant barriers remain for disabled learners in medicine. This paper develops the concept of the capability imperative , derived from a constructivist grounded theory study examining disability inclusion at four U.S. medical schools that analyzed technical standards policies and interviews with 19 disabled students and 27 school officials (faculty and administrators). Through three motifs (the selfless superhuman ; the "real world" of medicine ; and the malleable student), the capability imperative enforces the characteristics of a good physician, justifies institutional arrangements, and seeks to produce a learner who can conform to these expectations. Drawing on critical disability theories of ableism and crip theory, the paper argues that the capability imperative represents a context-specific manifestation of ableism that upholds a cultural logic of compulsory hyper-ablebodiedness and mindedness. This logic is antithetical to inclusive goals. Exploration of what constitutes a physician and whom this vision serves may help to shift the professional culture towards justice and unroot disabled peoples' ongoing marginalization in the medical profession. [ABSTRACT FROM AUTHOR]

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots – so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation. • Innovation intermediaries mobilize evidence from pilot studies to spread innovation. • Pilot-based evidence can link early adoption to wider spread and sustainability. • Mobilizing involves co-creating multiple forms of evidence with different groups. • Intermediary roles allow transitioning of pilot-based evidence into wider adoption. • Pilotitis involves a failure to transition evidence along the innovation journey. [ABSTRACT FROM AUTHOR]

This paper explores the complex relationships between recognition, collective action, and social (in)visibility of health conditions. We trace how collective action for recognition changes as conditions of visibility shift. We investigate how the Covid-19 global pandemic thrust one health condition (anosmia) and collective efforts around its recognition from almost complete public invisibility into a sudden spotlight. We show how 'prepared' movement actors leveraged this sudden hypervisibility to mobilize resources and change cultural values, noting how prior 'recognition work' becomes a resource for new ways to advocate for their condition's recognition, toward epistemic and institutional recognition: from building a shared epistemic ground and improving relatability, toward resource distribution and finally, creating and institutionalizing new cultural values through policy change. Our findings highlight organizational efforts to mitigate community tensions and dispersions related to hypervisibility, through boundary and integration work. • Anosmia was a socially invisible condition until Covid-19. • Collectives around socially invisible conditions organize to gain recognition. • We found that recognition work changes when social visibility shifts. • Shifts in visibility orient recognition work towards institutional parity of esteem. • Hypervisibility may lead to tensions and dispersions, requiring boundary work. [ABSTRACT FROM AUTHOR]

The aim of this paper is to track the whereabouts of basic old-age insurance (BOI) contribution subsidies. Little research has paid attention to the misalignment between the implementation objects of subsidy policies and the actual beneficiaries. In recent years, local governments in China have followed a contribution subsidy policy to help persons with disabilities (PWDs) with lower life expectancies. This study applied an actuarial model to calculate the leakage rate of the BOI contribution subsidy. The primary data are from the life tables of the entire population and PWDs in K province in China in 2015. It was found that, under different booking interest rates, 35.27%–61.26% of the contribution subsidy for PWDs in the individual account will be inherited by their heirs, and under different discount rates, 18.21%–68.74% in the pooling account will be enjoyed by non-disabled participants. The policy of BOI contribution subsidy for PWDs failed to account for the shorter average life expectancy and the lower average income of PWDs and would result in a welfare loss for PWDs. Therefore, it was suggested that it should be replaced by a non-contributory pension policy for PWDs. • Track the whereabouts of basic old-age insurance (BOI) contribution subsidies. • Built an actuarial model to calculate the leakage rate of contribution subsidy. • 35%–61% of the contribution subsidy for PWDs will be inherited by their heirs. • 18%–69% in the pooling account will be enjoyed by non-disabled participants. [ABSTRACT FROM AUTHOR]

In many parts of the world access to adequate water, sanitation and hygiene (WASH) is entwined with gender relations. While there is emerging research on how gender relations intersect with socio-cultural practices and norms to produce gender-based violence in WASH, little is known about how these gender relations are intimately produced, reproduced and embodied in place. Drawing insights from feminist political ecology and gendered geographies of power, this paper uses retrospective narratives of Ghanaian migrants in Canada to advance this scholarship in three significant ways. First, the findings demonstrate how gender relations in WASH produce everyday vulnerabilities differently among women and men. Second, they highlight the complex ways women bargain with patriarchal structures to ensure their safety in WASH spaces. Finally, the findings show how gender relations and roles in WASH transform in transnational spaces in which gendered WASH roles and responsibilities are blurred. The findings draw policy attention to the interconnectedness of WASH and gender equality and the need for policy and practice change to advance gender equity in WASH. • Water, sanitation and hygiene (WASH) security is entwined with gender relations. • Gender relations intersect with socio-cultural practices and norms to (re)produce gender-based violence in WASH. • Women bargain with patriarchal structures to ensure their safety in WASH spaces. • Gender relations and roles in WASH are reconstituted across space and time. [ABSTRACT FROM AUTHOR]

The COVID-19 epidemic has highlighted the risks of shortages resulting from dependence on medicine imports. Today's situation where a few companies in the Global North control COVID-19 vaccine production is having dire consequences on African countries' access. However, the challenges surrounding local production of medical products in Africa are long-standing issues dating back to independence. Using Ghana as a case study, this paper looks primarily at how the dependence on medicine imports can be understood as the result of policies implemented since independence, as well as the changes that the Ghanaian State has undergone in reaction to international events and the evolution of the structure of global pharmaceutical capital. It examines the policies associated with the Ghanaian State's project to promote local pharmaceutical production, from independence to the present, and the role that non-state actors such as pharmaceutical companies have played. Based on an historical political economy approach, it highlights how the roles of the State and its forms of intervention have evolved over time, from planning (right after independence), to implementing (during the global crisis of the 1970s–1980s), and finally to regulating (from the 1990–2000s onward). This paper draws on 14 months of PhD research fieldwork (2014–2018). It consists of interviews (n = 50) with Ghanaian actors in the pharmaceutical sector, observations in a pharmaceutical plant in Accra, and research into archives at the Public Records and Archives Administration Department (PRAAD) of the Ministry of Industry. • Dependence on medicine imports in Africa increases the risks of drugs shortages. • Importation may not be sufficient to adjust quickly to local pharmaceutical needs. • Local production may be better at identifying and responding to local health needs. • The State is instrumental in aligning industrial and public health policies. [ABSTRACT FROM AUTHOR]

All health systems struggle with unlimited needs for healthcare, yet limited resources with which to address them. Under national health insurance systems, policymakers must make explicit and potentially contested decisions around resource allocation. Policymakers have recognized the need to include public values in decisions regarding the distribution of resources across competing health priorities. Given the complex nature of these decisions, however, research into how to effectively measure public preferences is underdeveloped. Measuring community values poses special challenges since they involve normative judgments that can be interpreted differently across individuals and communities. Researchers have previously proposed integrating two methods that are currently used for measuring public preferences around healthcare services: i) an individual survey instrument, the Discrete Choice Experiment (DCE) and ii) a group-based model that incorporates informed opinions and deliberative dialogue, Citizen Juries (CJs). This current paper proposes a framework for implementing that integration and assesses methodological issues in the integration of DCEs and CJs, including issues of generalizability and validity. CJs and DCEs have conflicting epistemological and methodological foundations, which impact how researchers might analyze results of the integrated method. Researchers and policymakers interested in measuring social values should determine the philosophical orientation of their research question prior to study design, which will assist in choosing an appropriate research method. Further research is needed to investigate the empirical validity of the integrated method and how it may be implemented to maximize public acceptance. Advancing these methods can provide an improved instrument for capturing public preferences for policymakers tasked with priority setting in diverse contexts. • Universal healthcare systems often incorporate public values into priority setting. • Citizen Juries and Discrete Choice Experiments are two methods commonly used. • Combining these methods could improve a communitarian measurement of public values. • This paper analyzes ethical and methodological differences between these methods. • This paper also proposes a framework for empirical testing of the combined approach. [ABSTRACT FROM AUTHOR]

In this conceptual paper, we argue that at times of crisis, what is sometimes called "evidence-based" or "science-driven" policymaking—establishing scientific truths and then implementing them—must be tempered by a more agile, deliberative and inclusive approach which acknowledges and embraces uncertainty. We offer pragmatism as one potential option, using examples from the UK to illustrate how such an approach might have changed particular crisis decisions and led to better outcomes. We propose that to better prepare for the next public health crisis, five pragmatism-informed shifts are needed in the science-policy relationship: from scientism to science-informed narrative rationality that emerges from practice; from knowledge-then-action to acting judiciously under uncertainty; from hierarchies of evidence to pluralist inquiry; from polarized camps to frame-reflective dialogue; and from an "inside-track" science-policy dialogue to greater participatory democracy. We suggest an agenda for a pragmatist-informed program of applied research on crisis public health policymaking. • Conceptual paper arguing for pragmatism in crisis public health policymaking. • Particularly in crises, certainty is elusive; there is no single scientific truth. • Deliberate on real-world problems from multiple epistemological and moral angles. • Surface and explore how different actors frame and assign meaning to an issue. • Link ideas to emergent action with (rather than on) partner communities. [ABSTRACT FROM AUTHOR]

Universal health coverage (UHC) has become an influential global health policy. This study asked whether and to what extent UHC became a "hegemonic" health policy. The article consists of three parts: a historical timeline of UHC's rise, a bibliometric analysis of UHC in the literature, and a qualitative thematic analysis of how UHC is defined and the thematic content of those definitions. The roots of UHC can be traced to policies enacted by international financial institutions (IFIs) such as the World Bank and International Monetary Fund (IMF) during the latter half of the twentieth century. These policies caused the debt of low- and middle-income countries (LMICs) to rise precipitously and led the same IFIs and other institutions like the World Health Organization to become involved in the development and restructuring of health systems. UHC was presented as the leading method for financing development of health systems. As the bibliometric analysis shows, UHC has come to predominate in the literature around health system reforms. The thematic analysis based on a random selection of papers obtained in the bibliometric component of the study shows that often the term is not defined or only poorly defined. There is wide variation in the definitions, with many papers mentioning concepts such as quality, access, and equity without further clarification. Usually, papers define UHC to include tiering of benefits, with discussions of financing that focus on preventing "catastrophic [individual] expenditures" rather than discussing universal budgeting of a national health care system or national health insurance. We conclude that UHC has become hegemonic within global health policy, to the exclusion of discussions about other approaches to the transformation of health systems that are not predominately based on insurance coverage such as Health Care for All system, a system which provides equal services for the entire population. • Universal health coverage (UHC) has become hegemonic in global health policy. • UHC emerged largely as an initiative of international financial institutions. • UHC predominates in the literature and is often poorly defined or not defined. • Discussions of finances focus on individual spending instead of global budgeting. • UHC's hegemony diverts attention from other policies such as Health Care for All. [ABSTRACT FROM AUTHOR]

Market-driven health care reforms and development strategies continue to drive the privatization of health care services across the world. When these measures are implemented, large disparities emerge and are maintained. Using a modified version of the access to care framework developed by Penchansky and Thomas, this paper examines the manifestations of inequity between private for-profit and public emergency care in the Greater Cairo Region and Asyut, Egypt. In-depth interviews with physicians working in both sectors reveals stark disparities in access between these two health care sectors in Egypt. Access issues identified include unaffordable care in the private sector, unavailable medical supplies and overcrowding in public hospitals, as well as a salary gap that drives health care workers from public to private practice, creating staffing shortages in public hospitals. The manifestations of these inequities are often severe, usually tangible, and according to health care providers, embodied in the experiences of service users. • Examines access to health care in and private emergency care in Egypt. • Expands Penchansky and Thomas access to care framework. • Reveals medical shortages, health system overcrowding and pay disparities drive health inequity. • Health system inequity manifest in severe and tangible effects embodied in user experiences. • Inequities in the contextual circumstances and health system performance should be addressed. [ABSTRACT FROM AUTHOR]

Opioid overdose events and deaths have become a serious public health crisis in the United States, and understanding the spatiotemporal evolution of the disease occurrences is crucial for developing effective prevention strategies, informing health systems policy and planning, and guiding local responses. However, current research lacks the capability to observe the dynamics of the opioid crisis at a fine spatial-temporal resolution over a long period, leading to ineffective policies and interventions at the local level. This paper proposes a novel regionalized sequential alignment analysis using opioid overdose events data to assess the spatiotemporal similarity of opioid overdose evolutionary trajectories within regions that share similar socioeconomic status. The model synthesizes the shape and correlation of space-time trajectories to assist space-time pattern mining in different neighborhoods, identifying trajectories that exhibit similar spatiotemporal characteristics for further analysis. By adopting this methodology, we can better understand the spatiotemporal evolution of opioid overdose events and identify regions with similar patterns of evolution. This enables policymakers and health researchers to develop effective interventions and policies to address the opioid crisis at the local level. The proposed methodology provides a new framework for understanding the spatiotemporal evolution of opioid overdose events, enabling policymakers and health researchers to develop effective interventions and policies to address this growing public health crisis. • New framework for understanding spatiotemporal dynamic of opioid overdose evolution. • Identifies patterns and regions for effective crisis interventions. • Fills the gap in fine spatial-temporal resolution research. • Guides policymakers in addressing the opioid overdose crisis. [ABSTRACT FROM AUTHOR]

Based on ethnographic fieldwork among men who have sex with men and transgender women in Tanzania, this article explores the various types of work that may go into enrolment into PrEP programming and using pre-exposure prophylaxis (PrEP). PrEP protects against HIV acquisition and is widely touted as an essential tool in 'ending AIDS by 2030'. While taking PrEP has often been portrayed as 'just taking a pill a day' in public health campaigns, a striking observation during fieldwork was that enrolling in PrEP programming and adhering to PrEP involved a wide range of tasks. Inspired by this fieldwork experience and the literature on sociology of work, more specifically illness work and patient work, we started to think of these tasks as work. This paper identifies the range of tasks that PrEP users in Dar es Salaam had to perform as part of their enrolment and usage of PrEP. We provide a description of these tasks, organised into three categories of work that we refer to as (a) readying work, (b) user work, and (c) social navigation work that jointly make up what we propose to call biomedical prevention work. We further suggest that this analytical framework can be applicable to other biomedical prevention methods in other contexts. • Describes what it may entail to use PrEP among key populations in Dar es Salaam • PrEP use among men who have sex with men and transgender women • We argue that PrEP users do 'work' to use PrEP as HIV prevention • Presents novel conceptual framework: Biomedical Prevention Work • Framework describes how people may take preventative care with biomedical technology [ABSTRACT FROM AUTHOR]

The allocation of public care services should be determined by individual needs, but can be influenced by economic factors. This paper examines the impact of economic incentives on the allocation of public nursing home care in the Norwegian long-term care system. In Norway, municipalities and city districts have economic incentives for choosing nursing home care for high-income individuals in need of care and home-based care in sheltered housing for low-income individuals. The study uses a theoretical model and empirical data from the municipality of Oslo to determine if nursing home spots are allocated based on income, which would be financially advantageous for the city districts. We do not find evidence that the economic incentives of the care provider play a role in the allocation of nursing homes. Thus, in this setting, needs seem to be the dominant factor for allocation of nursing home care, while economic incentives seem to play no significant role. The clear legal mandate to provide services based on needs only is likely an important factor in this. • The study explores nursing home care allocation in Oslo. • Results show nursing home spots allocated based on need, not financial incentives. • Findings suggest needs-based allocation is functioning well is this setting. • The clear legal mandate to provide services based on needs only is likely an important factor. • Future research to focus on private care and optimal allocation. [ABSTRACT FROM AUTHOR]

This paper examines an influential randomised control trial (RCT) that aimed to identify how to recruit the best community health workers (CHWs) in Zambia. The economists who designed the RCT found that when they used job advertisement posters that emphasised future career prospects, they attracted applicants who were more "effective" health workers (according to various quantitative measures). The Zambian government accepted this policy advice and recruited thousands of new CHWs using posters that highlighted the career path available. However, since rolling out the programme nationally, the Zambian government has not built a career ladder into this position and the recruitment process has offered false hope to those who were selected. While acknowledging the responsibility of the Zambian government, this paper analyses the role of the RCT in this outcome. Drawing on ethnographic research and interviews conducted between 2019 and 2020, the paper shows how the RCT was flawed. The economists who designed the RCT framed it as a study of "bureaucrats" and "civil servants" and therefore overlooked crucial academic and policy debates about the distinctive role of CHWs – including the well-documented reluctance of governments to offer them careers. By failing to consider the political context of the CHW programme, the economists who designed the RCT provided policy advice that "worked" for the Zambian government in the short-term but which has ultimately been harmful to CHWs. Drawing on this case study, the paper contributes to the growing critical scholarship on RCTs and raises questions about whether these studies objectively improve policymaking, as many of their proponents claim. • Randomised control trials (RCTs) are increasingly used to inform policy-making. • Proponents of RCTs often overlook key ethical and political issues involved. • RCTs can cause considerable harm when these issues are overlooked. • Especially when RCTs involve people whose voices are marginalised in policy-making. • Researchers should focus on the politics/ethics of designing and implementing RCTs. [ABSTRACT FROM AUTHOR]

Growing health inequities among the increasingly diverse population in Aotearoa New Zealand have prompted responses in the healthcare system. Diversity-related policies and programmes have been developed in some District Health Boards (DHB) to address the issues. The translation of such policy into practice is, however, convoluted by subjective interests and power differentials and thus the outcomes of policies may deviate from their original objectives. In this paper we examine how staff in one DHB translate and implement health equity and diversity initiatives in their everyday practices in hospital settings. In high-level institutional thinking, Māori health equity policy is dictated by the Treaty of Waitangi which sets it apart from the cultural competence focus of programmes for other ethnic groups. Drawing on interviews with clinical staff in the DHB, we reveal how intersecting subject positions, including personal histories and institutional roles, influence the interpretation and enactment of these policies and programmes in ways that blur their distinct agendas. As a result, the paper demonstrates how the politics that underpin agendas that distinctly address equity and diversity, as well as the potential for change in these areas, can be compromised in everyday practice on the hospital floor. • Health equity policy programmes distinct for Māori and culturally diverse groups. • Distinct agendas are blurred as clinical staff translate them into practice. • Intersection of personal subjectivities and positionalities influence translations. • Blurring of agendas in everyday practice compromise potential for change. [ABSTRACT FROM AUTHOR]

The study of spatial accessibility to healthcare services is key to health policy (Pförtner et al., 2019; Vergier et al., 2017). Terms such as 'rurality' or 'medical desertification' were employed to stress the relevance of the topic. Within the existing literature, there is little (if any) concern with the legitimacy of the existing ways to measure inequality. Expert systems were assumed to be in place, and discrepancies or consistency with existing regulations or to views of relevant stakeholders were not considered. This paper discusses spatial accessibility of medical services in three distinct approaches: normative, that is following what national regulations consider as standard; relative, that is what statistical approaches reveal; consensual, which adjusts the indexes based on representations of stakeholders. The three approaches are compared for the case of Romania, an EU country with low population density, ideal to inspect geographical discrepancies. For the relative and the consensual approach, population is adjusted according to different demand expressed by age groups, and also including population and providers from the nearby localities. The normative approach follows official regulations. The refinements in the consensual model are based on survey data from stakeholders and consider distances to neighbouring localities and adjustments according to the age structure of the population in the catchment area. The results reveal high consistency between the consensual and the relative approach. Both are more permissive with respect to detecting medical desertification as compared to the normative approach but prove to be more effective in directing policy when resources are scarce. The normative approach, however, is relevant in depicting the state of the system as contrasted to a desired standard. The relative approach also overlaps with the consensual one. Therefore, to fully characterize spatial accessibility to general practitioners (GPs) and pharmacies, one needs to consider at least the normative and the relative approaches. • Different measurements of spatial access to healthcare overlap only partly. • The relative approach proves its legitimacy. • Relative and consensual approaches better grasp areas under risk. • Normative approaches are more effective to compare to a desired standard. • A multifaceted approach to spatial accessibility is recommended. [ABSTRACT FROM AUTHOR]

Many developing countries are considering insurance as a means of pursuing Universal Health Coverage. A key challenge to confront is how to achieve high levels of health insurance enrolment. For voluntary schemes this entails mass awareness raising and promotional activity, though as schemes move to compulsory enrolment, monitoring and enforcement are required. This paper focuses on Ethiopia, which has made state health insurance for the informal sector a central pillar of its Universal Health Coverage strategy. The paper shows that high enrolment requires particular forms of state capacity, captured by Michael Mann's concept of state 'infrastructural power'. The paper draws on detailed case studies of insurance implementation in the Tigray and Oromiya regions of Ethiopia to illustrate variation in state infrastructural power and the implications for health insurance. Findings suggest that the potential of state health insurance as a means of promoting health access for a broad section of the population may be limited to the minority of countries or regions within countries exhibiting high levels of infrastructural power. • State capacity is required for insurance to contribute to Universal Health Coverage. • State capacity is conceptualised in terms of the state's 'infrastructural power'. • Sub-national analysis in Ethiopia compares factors shaping insurance enrolment. • Cases show infrastructural power is an important factor shaping insurance enrolment. • For insurance to contribute to UHC, states require strong infrastructural power. [ABSTRACT FROM AUTHOR]

In many parts of the world nursing home residents have experienced a disproportionate risk of exposure to COVID-19 and have died at much higher rates than other groups. There is a critical need to identify the factors driving COVID-19 risk in nursing homes to better understand and address the conditions contributing to their vulnerability during public health crises. This study investigates the characteristics associated with COVID-19 cases and deaths among residents in U.S. nursing homes from 2020 to 2021, with a focus on geospatial and racial inequalities. Using data from the Centers for Medicare and Medicaid Services and LTCFocus, this paper uses zero-inflated negative binomial regression models, Kruskal-Wallis tests, and Local Moran's I to generate statistical and geospatial results. Our analysis reveals that majority Hispanic facilities have alarmingly high COVID-19 cases and deaths, suggesting that these facilities have the greatest need for policy improvements in staffing and financing to reduce racial inequalities in nursing home care. At the same time we also detect COVID-19 hot spots in rural areas with predominately White residents, indicating a need to rethink public messaging strategies in these areas. The top states with COVID-19 hot spots are Kentucky, Pennsylvania, Illinois, and Oklahoma. This research provides new insights into the socio-spatial contexts and inequities that contribute to the vulnerability of nursing home residents during a pandemic. • Geographic and racial inequalities are important indicators of covid-19 risk. • Covid-19 cases & deaths are high among facilities with majority Hispanic residents. • Facilities with majority Hispanic residents have high covid-19 vaccination rates. • Most covid-19 hot spots of cases & deaths are in predominantly White, rural areas. • The top states with covid-19 hot spots of cases & deaths are KY, PA, IL, and OK. [ABSTRACT FROM AUTHOR]

There is a growing concern that inequalities are hindering health outcomes. This paper's primary objective is to investigate the role of relative deprivation and inequality in explaining the daily spread of the Covid-19 pandemic. For this purpose, we use secondary cross-sectional data across 119 (developed and developing) countries from January 2020 – to April 2021. For the empirical analysis, we use a recent dynamic panel data modelling approach that allows us to identify the role of time-invariant variables such as degree of globalisation, political freedom and income inequality on the dynamics of the pandemic and fatality rates across countries. We find that new cases per million and fatality rates are highly persistent processes. After controlling for time-varying mobility statistics from the Google mobility database and region-specific dummy variables, the two significant factors that explain the severity of Covid-19 spread in a country are per-capita Gross Domestic Product (GDP) and Yitzhaki's relative income deprivation index. Lagged value of new cases per million significantly explains cross-country variations in the daily case fatality rates. A higher proportion of the older population and pollution increased fatality rates while better medical infrastructure reduced it. • Higher inequality led to a faster spread of Covid-19 cases. • Per-capita GDP has a positive and significant effect on Covid-19 cases. • Google mobility data is a good predictor of Covid-19 cases. • Faster spread of Covid-19 cases is associated with higher case fatality rates. • Pollution increased Covid-19 fatality rates. [ABSTRACT FROM AUTHOR]

While the overall impact of the COVID-19 pandemic on U.S. population health has been devastating, it has not affected everyone equally. The risks of hospitalization and death from the disease are relatively low for the population as a whole, but much higher for specific subpopulations defined by age, health status, and race or ethnicity. The extent to which Americans perceive these disparities is an open question, with potentially important political implications. Recognition of unequal impacts may prime concerns about justice and fairness, making Americans more concerned and willing to support government intervention. On the other hand, belief that the pandemic primarily threatens "other people" or out-groups may reduce, rather than increase, a person's concern. Partisanship and media consumption habits are also likely to play a role in these perceptions, as they do in most issues related to COVID-19. In this paper, we use original survey data from the Cooperative Election Study (N = 1000) to explore Americans' perceptions of which groups are most harmed by the pandemic, the demographic and political determinants of these perceptions, and the relationship of these perceptions with their opinions about COVID-related mitigation policy. We find that, on average, people perceived accurately that certain groups (e.g., Black Americans, older people) were more affected, but these group perceptions varied by demographic and political characteristics of respondents. We find, in contrast with recent experimental evidence, that the perception that populations of color were harmed was associated with more support for pandemic mitigation strategies. More research should investigate the relationships among pandemic politics and the racial dynamics of the target populations most affected. • In fall 2020, survey participants recognized groups harmed by COVID based on age. • They had lower recognition of racial groups harmed, lowest for Native Americans. • Perceptions of groups harmed varies by information exposure and politics. • Perceiving group disparities was associated with more support for pandemic policy. • The racial dynamics surrounding the politics of COVID-19 requires more attention. [ABSTRACT FROM AUTHOR]

Digital health technologies transform practices, roles, and relationships in medicine. New possibilities for a ubiquitous and constant data collection and the processing of data in real-time enable more personalized health services. These technologies might also allow users to actively participate in health practices, thus potentially changing the role of patients from passive receivers of healthcare to active agents. The crucial driving force of this transformation is the implementation of data-intensive surveillance and monitoring as well as self-monitoring technologies. Some commentators use terms like revolution, democratization, and empowerment to describe the aforementioned transformation process in medicine. The public debate as well as most of the ethical discourse on digital health tends to focus on the technologies themselves, mostly ignoring the economic framework of their design and implementation. Analyzing the transformation process connected to digital health technologies needs an epistemic lens that also considers said economic framework, which I argue is surveillance capitalism. This paper introduces the concept of liquid health as such an epistemic lens. Liquid health is based on Zygmunt Bauman's framing of modernity as a process of liquefaction that dissolves traditional norms and standards, roles, and relations. By using liquid health as an epistemic lens, I aim to show how digital health technologies reshape concepts of health and illness, change the scope of the medical domain, and liquify roles and relationships that surround health and healthcare. The basic hypothesis is that although digital health technologies can lead to personalization of treatment and empowerment of users, their economic framework of surveillance capitalism may undermine these very goals. Using liquid health as a concept allows us to better understand and describe practices of health and healthcare that are shaped by digital technologies and the specific economic practices they are inseparably attached to. • Data-intensive technologies detach health from fixed meanings, relations, and domains. • This process can best be described as liquefaction, following Bauman's approach. • Health data becomes free-floating due to ubiquitous and permanent surveillance. • Liquid health is exterritorial, freed from restrictions by space and time. • Liquid health is socially exterritorial , freed from established norms in health care. [ABSTRACT FROM AUTHOR]

Increasing food and nutritional inequities are apparent in urban settings across Low- and Middle-Income Countries (LMICs), along with nutrition transition towards ultra-processed diets high in fat, sugar, and salt. In urban informal settlements, characterized by insecurity and inadequate housing and infrastructure, food systems dynamics and their nutritional implications are poorly understood. This paper explores the food system determinants of food and nutrition security in urban informal settlements in LMICs with the goal of identifying effective approaches and entry points for policy and program. Scoping review. Five databases were screened spanning the period 1995 to 2019. A total of 3748 records were assessed for inclusion based on title and abstract followed by 42 full text reviews. At least two reviewers assessed each record. Twenty-four final publications were included, coded, and synthesized. Factors influencing food security and nutrition in urban informal settlements can be organized into three interconnected levels. Macro-level factors include globalization, climate change, transnational food corporations, international treaties and regulations, global and national policies such as SDGs, insufficient social aid programs, and formalization or privatization. Meso-level factors include gender norms, inadequate infrastructure and services, insufficient transportation, informal food retailers, weak municipal policies, marketing strategies, and (lack of) employment. Micro-level factors comprise gender roles, cultural expectations, income, social networks, coping strategies, and food (in) security. Greater policy attention should focus at the meso-level, with priority investments in services and infrastructure within urban informal settlements. The role and engagement of the informal sector is an important consideration in improving the immediate food environment. Gender is also crucial. Women and girls have a central role in food provisioning but are more vulnerable to various forms of malnutrition. Future research should include context-specific studies in LMIC cities as well as promoting policy change using a participatory and gender transformative approach. • Interconnected macro, meso & micro level factors shape inequities in urban food systems. • AcTion is needed to improve the immediate food environment in informal settlements. • The informal food sector is critical to the urban poor with overlooked potential. • Women are key to household food provisioning and need to be supported. [ABSTRACT FROM AUTHOR]

Power and politics are both critical concepts to engage with in health systems and policy research, as they impact actions, processes, and outcomes at all levels in health systems. Building on the conceptualization of health systems as social systems, we investigate how power and politics manifested in the Finnish health system during COVID-19, posing the following research question: in what ways did health system leaders and experts experience issues of power and politics during COVID-19, and how did power and politics impact health system governance? We completed online interviews with health system leaders and experts (n = 53) at the local, regional, and national level in Finland from March 2021 to February 2022. The analysis followed an iterative thematic analysis process in which the data guided the codebook. The results demonstrate that power and politics affected health system governance in Finland during COVID-19 in a multitude of ways. These can be summarized through the themes of credit and blame, frame contestation, and transparency and trust. Overall, political leaders at the national level were heavily involved in the governance of COVID-19 in Finland, which was perceived as having both negative and positive impacts. The politicization of the pandemic took health officials and civil servants by surprise, and events during the first year of COVID-19 in Finland reflect recurring vertical and horizontal power dynamics between local, regional, and national actors. The paper contributes to the growing call for power-focused health systems and policy research. The results suggest that analyses of pandemic governance and lessons learned are likely to leave out critical factors if left absent of an explicit analysis of power and politics, and that such analyses are needed to ensure accountability in health systems. • Power and politics affect outcomes and processes at all levels of the health system. • Power and politics can be empirically studied through a focus on health system governance. • We studied how power and politics affected the governance of COVID-19 in the Finnish health system. • Interviews (n = 53) with health system leaders revealed several themes of power and politics. • Themes included credit and blame, frame contestation, and transparency and trust. [ABSTRACT FROM AUTHOR]

The information set from which individuals make their decision on vaccination includes signals from trusted agents, such as governments, community leaders and the media. By implementing restrictions, or by relaxing them, governments can provide a signal about the underlying risk of the pandemic and indirectly affect vaccination take-up. Rather than focusing on measures specifically designed to increase vaccine acceptance, this paper studies how governments' non-pharmaceutical policy responses to the pandemic can modify the degree of preventive health behavior, including vaccination. To do so, we use repeated waves of a global survey on COVID-19 Beliefs, Behaviors and Norms covering 18 countries from October 2020 to March 2021. Controlling for the usual determinants, we explore how individuals' willingness to get vaccinated is affected by changes in government restriction measures (as measured by the Oxford Stringency Index). This relationship is mediated by individual characteristics, social norms (social pressure to conform with what most people do), and trust in government institutions. Our results point to a complex picture as the implementation of restrictions is associated with increased acceptance in some contexts and decreased acceptance in others. The stringency of government restrictions has significant positive correlations with vaccine acceptance in contexts of weak social norms of vaccine acceptance and lower trust in government. In countries or communities with tighter social norms and high trust in health authorities, vaccine acceptance is high but less sensitive to changes in policies. These results suggest that the effect of government policy stringency is stronger among individuals who report lower trust and weaker social norms of vaccine acceptance. • Reports results from the analysis of an online survey on health behaviors during the COVID-19 • Provides evidence on the relationship between vaccine acceptance and lockdown policies • Finds stricter non-pharmaceutical interventions are associated with higher vaccine acceptance • Shows that this association is stronger for individuals with lower trust in health authorities [ABSTRACT FROM AUTHOR]

As a term used in nursing and other health professions to describe when one is prevented by institutional constraints from pursuing the right course of action, moral distress has gained traction to examine the effects of restructuring on health and social care providers. Using a critical narrative methodology, this paper presents the counter-stories of nine pediatric oncology nurses in Ontario, Canada, whose stories illustrate the embeddedness of their caregiving and moral distress within institutional contexts that leave them stretched thin amongst multiple caregiving and administrative demands, and that limit their capacities to be the nurses they want to be. Informed by feminist philosophical theorizations of moral distress, we elucidate how the nurses' counter-stories: (i) re-locate the sources of their moral distress within institutional constraints that fracture their moral identities and moral relationships, and (ii) dis-locate dominant narratives of technological cure by ascribing value and meaning to the relational care through which they sustain moral responsibilities with patients and their families. By making visible the relational care that they find meaningful and that brings them in proximity to patients and families, these counter-stories assist nurses in restoring their damaged moral identities. This study demonstrates the power of identifying and mobilizing counter-stories in tracing and critically examining the conditions that structure nurses' experiences of moral distress. The findings add theoretical and empirical depth to contemporary understandings of moral distress and complement ongoing public discussion of burnout among nurses and other health care workers during the COVID-19 pandemic. These counter-narratives may act as resources for resistance among nurses, help to reduce the distance between management and health care workers, and catalyze changes in policy and practice so that nurses, and the full scope of their caregiving, are valued. • Counter-stories challenge dominant constructions of healthcare and caregiving. • Moral distress is embedded in institutional constraints that fracture moral identities. • Nurses' counter-stories assign meaning to relational care and moral responsibilities. • Nurses' fractured moral identities are restored through counter-stories. • Counter-stories act as narrative resources for resistance and resilience among nurses. [ABSTRACT FROM AUTHOR]

A major challenge in managing disasters during a pandemic is assessing the inequalities in society and protecting vulnerable people. The objective of this paper is to geographically understand the discrimination and inequality against minorities by COVID-19. This study designed a locational discrimination index (LDI) to measure COVID-19 discrimination against minorities at county-level in the US. LDI is the difference between the death proportion of a minority and the proportion of a minority's population. If LDI >0 is significant, COVID-19 discrimination is identified against a minority in a county. I further developed a locational minority inequality index (LMII), and LMII of a minority is directly quantified by comparing its LDI with the LDI of the majority population (i.e., the White population in the US). If LMII>0 is significant, a significant health inequality is confirmed against a minority in a county. In the US, I found 157 counties with significant discrimination against Black people, and 103 counties with significant inequality against Black people; 58 counties with significant discrimination against the American Indian population, but 38 counties with significant inequality against the American Indian population; 17 counties with significant discrimination against Native Hawaiians, but only 8 counties with significant inequality; for Hispanic people, 47 counties had significant discrimination, and 64 counties had significant inequality; for Asians, 7 counties had significant discrimination, but 28 had significant inequality. LDI, LMII, and the thematic mapping provide novel insight into COVID-19 discrimination and inequalities. To the best of our knowledge, this is the first time anyone has quantitatively and statistically defined and mapped COVID-19 discrimination and inequality against minorities at a county-level across the US. Based on this, governments and communities could make efficient decisions and take effective action to addressthe significant discrimination and inequality against Black, American Indian, Native Hawaiian, Hispanic, and Asian people, which can be applied to other pandemics or public health disasters in the USA or other countries. • The significant discrimination and inequality of COVID-19 are tested and mapped. • Locational discrimination index to quantify minority's vulnerability is developed. • Locational minority inequality index is developed to further compare inequality in vulnerability. • COVID-19 caused significant spatial inequality between minorities and the white population in the USA. [ABSTRACT FROM AUTHOR]

Socioeconomic inequalities in childhood Body Mass Index (BMI) are becoming increasingly more pronounced across the world. Although countries differ in the direction and strength of these inequalities, cross-national comparative research on this topic is rare. This paper draws on harmonized longitudinal cohort data from four wealthy countries—Germany, the Netherlands, the United Kingdom (UK), and the United States (US)—to 1) map cross-country differences in the magnitude of socioeconomic inequalities in childhood BMI, and 2) to examine cross-country differences in the role of three energy-balance-related behaviors—physical activity, screen time, and breakfast consumption—in explaining these inequalities. Children were aged 5–7 at our first timepoint and were followed up at age 8–11. We used data from the German National Educational Panel Study, the Dutch Generation R study, the UK Millennium Cohort Study and the US Early Childhood Longitudinal-Kindergarten Study. All countries revealed significant inequalities in childhood BMI. The US stood out in having the largest inequalities. Overall, inequalities between children with low versus medium educated parents were smaller than those between children with high versus medium educated parents. The role of energy-balance-related behaviors in explaining inequalities in BMI was surprisingly consistent. Across countries, physical activity did not, while screen time and breakfast consumption did play a role. The only exception was that breakfast consumption did not play a role in the US. Cross-country differences emerged in the relative contribution of each behavior in explaining inequalities in BMI: Breakfast consumption was most important in the UK, screen time explained most in Germany and the US, and breakfast consumption and screen time were equally important in the Netherlands. Our findings suggest that what constitutes the most effective policy intervention differs across countries and that these should target both children from medium as well as low educated families. • All countries showed substantial socioeconomic inequalities in childhood BMI. • In all countries, inequalities in BMI steepen over course of primary school. • Protective factors among the most advantaged seem to mainly drive inequalities. • Across most countries, underlying mechanisms for inequalities in BMI are similar. • The relative contribution of each mechanism to BMI inequalities differs per country. [ABSTRACT FROM AUTHOR]

The consumption of tobacco, alcohol and ultra-processed foods and beverages drives the global noncommunicable disease (NCD) crisis in Pacific small island developing states (PSIDS). Addressing the commercial determinants of health (CDoH) requires policy coherence across government sectors; however, entrenched neoliberal ideologies that exhort self-regulation of markets and market actors impede such efforts. This paper aims to explore the roles ideas play in governing CDoH, through the analysis of causal ideas in multisectoral tobacco governance in Fiji and Vanuatu. An explorative, qualitative case study design was applied. Data collection relied primarily on in-depth interviews, of which 70 were conducted between 2018 and 2019. Data analysis was guided by a theory-informed analytical framework. Two causal ideas influence multisectoral tobacco governance in Fiji and Vanuatu. According to the idea of individual responsibility, high smoking prevalence is the consequence of individuals' unhealthy lifestyle choices; it nominates the Ministry of Health as the responsible actor to solve this issue by providing health education. In contrast, the idea of CDoH argues that harmful commodity industries drive the NCD epidemic, and the sectors that regulate these private actors should be kept in closer check to ensure that their policies are aligned with the objectives of public health. In Fiji and Vanuatu, the non-health government agencies are effectively excused from implementing multisectoral tobacco policies because the dominant idea of individual responsibility relieves them of any responsibility. The wider adoption of the idea of CDoH is needed in PSIDS to tackle the NCD crisis. • Causal ideas are used to identify responsible actors and solutions to the NCD crisis. • The idea of individual responsibility excuses non-health actors from multisectoral action. • The idea of commercial determinants of health (CDoH) promotes multisectoral policies. • In Fiji and Vanuatu the idea of individual responsibility dominates tobacco control. • The diffusion of the idea of CDoH is needed to tackle NCDs in Fiji and Vanuatu. [ABSTRACT FROM AUTHOR]

Drawing on interviews conducted in 2019–2020, across twenty villages in India, this paper unpacks how people with chronic illness navigate complex care-seeking terrain. We show how the act of seeking care involves navigating through personal, family, social, economic, cultural, and most importantly, difficult health systems spaces—and entails making difficult social, moral, and financial choices. We show how the absence of reliable and accessible points of first contact for primary care results in people running from pillar to post, taking wrong turns, and becoming disappointed, frustrated, and, sometimes, impoverished. We reveal the complex individual and social dynamics of hope and misplaced and misguided expectations, as well as social obligations and their performance that animate the act of navigating care in rural India. We shine light on how a health system with weak primary care and poor regulation amplifies the medical, social, and financial consequences of an otherwise manageable chronic illness, and how these consequences are the worst for those with the least social, network and economic capital. Crucially we highlight the problematic normalisation of the absence of reliable primary care services for chronic illness in India, in rural India specifically. We signpost implications for research, and for policy and practice in India and similar health system contexts, i.e. those with weak primary care and poor regulation of the private sector. We argue that in India, having in place accessible, good quality, and trustworthy sources of advice and care for chronic illness at the first point of call, for all, is critical. We contend that this first point of call should be quality, public primary care services. We conclude that if such arrangements are in place in public services, people will use them. • Lack of reliable, trustworthy advice and care is a big gap in India's health system. • Being misled and suffering catastrophic consequences of ill-health is the result. • People need to be protected from bad actors in their care-seeking journeys. • People want reliable, trustworthy advice and care, at their first point of call. • India's health system must urgently act to ensure appropriate care at all levels. [ABSTRACT FROM AUTHOR]

Processes of neighborhood change are important determinants of health. One salient dimension of the experience of neighborhood changes is a person's evolving sense of empowerment over the changes around them, such as development of new housing or shifts in economic opportunity. Community residents collaborating on a Participatory Action Research study developed the novel construct "ownership of change" to capture this psychosocial process, and hypothesized that it may help explain the relationship between neighborhood change and health. In this paper, we describe our participatory process for developing a way to measure ownership of change, explore the construct's validity, test the hypothesis that it is associated with health, and analyze qualitative data to understand the process through which one's sense of ownership of change is produced. We argue that the construct is useful for studying the role of neighborhood changes in shaping health, and that building ownership over neighborhood change must be a key dimension of urban planning and policy for health equity. • The construct "ownership of change" was developed via Participatory Action Research. • Ownership of change captures empowerment over meso-level place-based changes. • Ownership of change is positively associated with health. • The structural conditions of racial capitalism influence ownership of change. • Ownership of change is key for achieving health equity in cities. [ABSTRACT FROM AUTHOR]

This paper studies the existence of international health outcome disparities. We focus on the use of the potential years of life lost for a database that includes information from 33 OECD countries and covers the period 1990–2017. The methodology proposed by Phillips and Sul (2007) allows us to reject the existence of a single pattern of behaviour between countries for both males and females, suggesting the existence of severe health outcome inequalities. This methodology estimates the existence of four convergence clubs whose composition slightly varies when comparing the male and female cases. Some socioeconomic factors are found to be very important in explaining the forces that may drive the creation of these convergence clubs. In particular, the evolution of the economy and health policies are pivotal to understanding the creation of these estimated convergence clubs. Additionally, our results offer evidence in favor of the importance of environmental policies to explain these health outcome differences. • We examine the disparities in the potential years of life lost for OECD countries. • We apply the Phillips and Sul (2007) methodology. • We find convergence clubs for both male and female data. • Economic, health and environmental factors are related these convergence clubs. [ABSTRACT FROM AUTHOR]

This study examines whether people smoked more under the Coronavirus Disease 2019 (COVID-19) closure policies which trapped them at home with their families. In such circumstances, the pleasure from smoking could be more tempting than usual, but at the same time smokers' families are more likely to be victims of passive smoking. This study uses temporal and regional variations in policy strengths with data from the Oxford COVID-19 Government Response Tracker project (OxCGRT) to examine the impact of COVID-19 closure policies on smoking behaviors. With longitudinal data from the China Family Panel Studies (CFPS) in 2018 and 2020, we find diminished smoking behaviors among Chinese male adults when the government implemented strict public health policies for the COVID-19 pandemic. People with more conscientiousness personality traits or stronger pro-family attitudes tend to smoke less as policy stringency increases. • This paper examines whether people smoke more under COVID-19 closure policies. • Policy stringency is the average OxCGRT score in the past 30 days before survey. • We find people smoke less when the index of policy stringency becomes higher. • Conscientious personality traits and pro-family attitudes are proxies of altruism. • The discouraging effects are stronger among people with higher family altruism. [ABSTRACT FROM AUTHOR]

Social science research has long critiqued how professional ideals of public service can ignore chronic problems within the healthcare industry, placing unfair burden on the "heroism" of individual workers. Yet, fewer studies investigate how healthcare professionals actively negotiate such demands for service, amidst increasing workplace pressures and risks. This paper studies Filipino nurses' response to a government policy that banned them from working overseas in order to channel their labor to local hospitals during the COVID-19 pandemic. Based on 51 in-depth interviews, we argue that nurses' willingness to serve in the Philippines' COVID-19 hospitals hinged on the point at which the deployment ban interrupted their emigration trajectories. Specifically, nurses' decision to heed their government's call to service depended on whether they saw local hospital experience as valuable for their plans of working abroad. We introduce the concept of "clocking out" to describe how aspiring nurse migrants set limits to the time they devote to local service, as they pursue a career pathway beyond national borders. We discuss how this concept can inform scholarship on nurse retention and professional values, especially for developing nations in times of crisis. • The Philippines banned its nurses from working abroad during the COVID-19 pandemic. • Filipino nurses either resisted or complied with the call to serve in local hospitals. • Migrant nurses view local clinical experience as necessary step towards jobs abroad. • Researchers must study professionalism in the context of migration trajectories. [ABSTRACT FROM AUTHOR]

In their paper "Integrating Network Theory into the Study of Integrated Healthcare," Burns, Nembhard and Shortell set out to change how we think about healthcare, and ultimately how we design and deliver healthcare. They aim to do this by focusing attention on the networks through which care is delivered, with particular attention to the relational dimensions of those networks. Inspired by social network, care integration, and relational coordination theories, Burns et al. (2022) offer recommendations for moving the healthcare sector toward a fresh approach to care integration that reflects the realities of relationships and networks. In this commentary, we analyze the main recommendations by Burns et al. and present our view of the field's current standing with regards to each of them. We then suggest potential research questions, contexts and designs to move this proposed work forward, drawing upon insights from a conversation with the authors in addition to their original article. We end by recommending the formation of a research collaborative to carry out the work. [ABSTRACT FROM AUTHOR]

With a goal of improving health system quality and efficiency, reforms of China's health system over the past decade have sought to strengthen primary healthcare in lower-level clinics and health centers. Despite these wide-ranging reforms and initiatives, population-based studies have documented dramatic declines in patients' use of primary care facilities during this period. In this paper, we explore the determinants of this trend in China's rural areas using detailed longitudinal data following a nationally-representative sample of rural households and village clinics from 2011 to 2018. We estimate that between 2011 and 2018, the probability that individuals sought care at village clinics when ill dropped by 44%. At the same time, the utilization of outpatient services in county hospitals increased by 56% and patient self-treatment increased by 20%. Detailed Kitagawa-Oaxaca-Blinder decompositions suggest four primary drivers of this trend: the shifting burden of disease in rural areas, changes in how patients choose to seek care given different disease conditions, declining drug inventory in village clinics, and the decreasing importance of remoteness as a determinant of healthcare seeking behavior. Our results highlight the deteriorating role of village clinics in the rural healthcare system and the increasing importance of self-treatment and higher-tier primary care services. • Recent policies in China have sought to strengthen primary care. • Despite this, rural primary care utilization in villages has continued to decline. • Utilization of village clinics has shifted to self-treatment and upper-tier facilities. • Decomposition analysis show four main factors driving this trend. • Results highlight a deteriorating role of village clinics in the health system. [ABSTRACT FROM AUTHOR]

Frameworks for understanding integrated care risk underemphasizing the complexities of the development of integrated care in a local context. The objectives of this article are to (1) present a novel strategy for conceptualizing integrated care as developing through a series of milestones at the organizational level, and (2) present a typology of milestones empirically generated through the analysis of four cases of integrated community-based primary health care (ICBPHC) in Canada and New Zealand. Our paper reports on an analysis of 4 specific organizational case studies within a large dataset generated for an international multiple case study project of exemplar models of ICBPHC. Drawing on earlier analyses of 359 qualitative interviews with patients, caregivers, health care providers, managers, and policymakers, in this article we present a detailed analysis of 28 interviews with managers and leaders of local models of integrated care. We generated a detailed timeline of the development of integrated care as expressed by each participant, and synthesized themes across timelines within each case to identify specific milestone events. We then synthesized across cases to generate the broader milestone categories to which each event belongs. We generated 5 milestone categories containing 12 more specific milestone events. The milestone categories include (1) strategic relational, (2) strategic process change, (3) internal structural, (4) inter-organizational structural, and (5) external milestones. We propose a comprehensive framework of developmental milestones for integrated care. Milestones represent a compelling strategy for conceptualizing the development of integrated care. Practically, policymakers and health care leaders can support the implementation of integrated care by examining the history and context of a given model of care and identifying strategies to achieve milestones that will accelerate integrated care. Further research should document additional milestone events and advance the development of dynamic frameworks for integrated care. • Developmental milestones accelerate or decelerate achievement of integrated care. • 5 categories of milestones are identified. • A comprehensive framework for milestones of integrated care is proposed. • Implementation strategies should be based on past milestones achieved. [ABSTRACT FROM AUTHOR]

In this paper, we trace how mathematical models are made 'evidence enough' and 'useful for policy'. Working with the interview accounts of mathematical modellers and other scientists engaged in the UK Covid-19 response, we focus on two weeks in March 2020 prior to the announcement of an unprecedented national lockdown. A key thread in our analysis is how pandemics are made 'big'. We follow the work of one particular device, that of modelled 'doubling-time'. By following how modelled doubling-time entangles in its assemblage of evidence-making, we draw attention to multiple actors, including beyond models and metrics, which affect how evidence is performed in relation to the scale of epidemic and its policy response. We draw attention to: policy; Government scientific advice infrastructure; time; uncertainty; and leaps of faith. The 'bigness' of the pandemic, and its evidencing, is situated in social and affective practices, in which uncertainty and dis-ease are inseparable from calculus. This materialises modelling in policy as an 'uncomfortable science'. We argue that situational fit in-the-moment is at least as important as empirical fit when attending to what models perform in policy. • Pandemics are performed as crises of uncertain yet catastrophic potential. • Mathematical models are forms of scalar narrative affording epidemics their scale. • Models and projections are made useful as evidence in their situated policy events. • Calculations are given agency as affects in the evidencing of pandemics. • Modelling pandemics is a site of 'uncomfortable science' and 'dis-ease'. [ABSTRACT FROM AUTHOR]

Central to the workings of a hospital are the technical and bureaucratic systems that ensure the effective coordination of information and biological materials of patients across time and space. In this paper, which is based on ethnographic research in a public referral hospital in Freetown, Sierra Leone, conducted between October 2018 and September 2019, we adopt a patient pathway approach to examine moments of breakdown and repair in the coordination of patient care. Through the in-depth analysis of a single patient pathway through the hospital, we show how coordination work depends on frequent small acts of intervention and improvisation by multiple people across the pathway, including doctors, managers, nurses, patients and their relatives. We argue that such interventions depend on the individualisation of responsibility for 'making the system work' and are best conceptualised as acts of temporary repair and care for the health system itself. Examining how responsibility for the repair of the system is distributed and valued, both within the hospital and in terms of broader structures of health funding and policy, we argue, is essential to developing more sustainable systems for repair. • Employed ethnographic methods to track patient pathways through hospitals. • Patient pathways are negatively impacted by breakdowns in the coordination of care. • Improvisatory work to ensure continuity of care is a form of health system repair. • Responsibility for repair often falls on the most vulnerable in a health system. • Relationships of repair are essential but undervalued components of health systems. [ABSTRACT FROM AUTHOR]

This study examined the context and drivers of HIV risk and vulnerability among male partners of female sex workers in Kampala, Uganda, using an "intersectional risk environment" framework. This research reports on findings from an ethnographic study (2016–2019) of men in one informal settlement in Kabalagala Parish in Kampala. This research included long-term participant observation in and around the study community. Thematic analysis was used to assess aspects of the risk environment and how it influences HIV/AIDS among male partners of female sex workers. The informal settlement context where sex work takes place is conceptualized here as a "risk environment," or a social-physical space in which risk and harm are produced (Rhodes, 2002). Risk is situated within a broader social and political structure that constrains choices and facilitates HIV risk, particularly for young, low-income men facing matrices of domination on the basis of age, gender, residence, and income. These intersectionalities guide experiences of HIV vulnerability in the risk environment, including physical, social, economic, and policy risks. This includes physical risks (population density, bar density), social risks (sex work, bar groups), economic risks (informal and low wage work), and political risks (anti-poverty laws and legislation, urban policy). These findings highlight how an intersectional risk environment is differentially experienced by young, low-income men to produce unequal HIV/AIDS outcomes. This research fills a gap in the literature on the context of HIV/AIDS among men, particularly high-risk men like male partners of female sex workers. Using this framework will improve understandings of HIV outcomes among male partners of female sex workers and will facilitate context-specific and adapted structural interventions for HIV/AIDS prevention and treatment. • Male partners of female sex workers are key in Uganda's HIV epidemic. • This paper uses an intersectional risk environment to understand HIV risk. • The risk environment includes intimate partnerships and men's bar groups. • Young men face additional risks due to unemployment and alcohol use. • Young men face higher rates of arrest due to over-policing in the community. [ABSTRACT FROM AUTHOR]