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High quality primary care is a foundational element of effective health services. Internationally, primary care physicians (general practitioners (GPs), family doctors) are experiencing significant workload pressures. How non-patient-facing work contributes to these pressures and what constitutes this work is poorly understood and often unrecognised and undervalued by patients, policy makers, and even clinicians engaged in it. This paper examines non-patient-facing work ethnographically, informed by practice theory, the Listening Guide, and empirical ethics. Ethnographic observations (104 h), in-depth interviews (n = 16; 8 with GPs and 8 with other primary care staff) and reflexive workshops were conducted in two general practices in England. Our analysis shows that 'hidden work' was integral to direct patient care, involving diverse clinical practices such as: interpreting test results; crafting referrals; and accepting interruptions from clinical colleagues. We suggest the term 'hidden care work' more accurately reflects the care-ful nature of this work, which was laden with ambiguity and clinical uncertainty. Completing hidden care work outside of expected working hours was normalised, creating feelings of inefficiency, and exacerbating workload pressure. Pushing tasks forward into an imagined future (when conditions might allow its completion) commonly led to overspill into GPs' own time. GPs experienced tension between their desire to provide safe, continuous, 'caring' care and the desire to work a manageable day, in a context of increasing demand and burgeoning complexity. • The non-patient-facing work of general practitioners is often invisible or hidden. • Hidden work is associated with complexity and uncertainty. • Behind-the-scenes work is care work, just as direct work with patients is care work. • Doctors face tensions between completing tasks and working a manageable day. • Combining practice theory with the Listening Guide embraces multi-vocality. [ABSTRACT FROM AUTHOR]

Discrete Choice Experiments (DCEs) are widely employed survey-based methods to assess preferences for healthcare services and products. While they offer an experimental way to represent health-related decisions, the stylized representation of scenarios in DCEs may overlook contextual factors that could influence decision-making. The aim of this paper was to evaluate the predictive validity of preferences elicited through a DCE in decisions likely influenced by a hot-cold empathy gap, and compare it to another commonly used method, a direct-elicitation question. We focused on preferences for pain-relief modalities, especially for an epidural during childbirth - a context where direct-elicitation questions have shown a preference for or intention to have a natural birth (representing the "cold" state), yet individuals often opt for an epidural during labor (representing the "hot" state). Leveraging a unique dataset collected from 248 individuals, we incorporated both the stated preferences collected through a survey administered upon hospital admission for childbirth and the actual pain-relief modality usage data documented in medical records. The DCE allowed for the evaluation of scenarios outside of those expected by respondents to simulate decision-making during childbirth. When we compared the predicted epidural use with the actual epidural use during labor, we observed a choice concordance of 71-60%, depending on the model specification. The concordance rate between the predicted and actual choices increased to 77-76% when accounting for the initial use of other ineffective modalities. In contrast, the direct-elicitation choices, relying solely on respondents' baseline expectations, yielded a lower concordance rate of 58% with actual epidural use. These findings highlight the flexibility of the DCE method in simulating complex decision contexts, including those involving hot-cold empathy gaps. The DCE proves valuable in assessing nuanced preferences, providing a more accurate representation of the decision-making processes in healthcare scenarios. • The concordance between the predicted and actual epidural use was 71%-60. • Concordance increased to 77-76% when accounting for prior use of ineffective options. • Direct-elicitation choices resulted in a concordance of 58% with actual epidural use. • DCE proved to be more flexible in predicting decisions with hot-cold empathy gaps. [ABSTRACT FROM AUTHOR]

Many Latinx and Indigenous Mexican populations in the United States Southwest live in unincorporated communities in the US-Mexico borderlands called colonias. These environmental justice communities often lack basic infrastructure, including healthcare services, prompting many to seek services across the border. However, due to geopolitical factors more vulnerable caregivers are limited to utilize healthcare services in the US. This paper reports the experiences and healthcare decision-making of caregivers living in colonias in the US-Mexico border region who care for children with respiratory health conditions. This study was carried out from September to December 2020. Focus groups and interviews were conducted with Latinx and Indigenous Mexican caregivers of children with asthma or respiratory distress. Qualitative interviews elicited caregivers' perspectives on the environmental factors affecting children's chronic health conditions and use of healthcare services. The analysis employed the concept of structure vulnerability to theorize geography as a structural determinant of health for caregivers faced with making healthcare decisions for their suffering from respiratory health conditions. A survey was administered to collect basic sociodemographic information. A total of 36 caregivers participated in the study. Structural factors including unincorporated community status and government inaction intersected with social determinants of health to prompt caregivers to cross the US-Mexico border to access healthcare services in Mexico for their children. Yet, more vulnerable caregivers (i.e., those without documentation status in the US) and their children, accessing healthcare services in the US was not an option limiting caregivers' ability to meet their children's healthcare needs. In such cases, geography acts as a structural determinant of health. This study shows the importance of geography in health. Rural unincorporated colonias located in the borderlands are precariously located and lack basic critical infrastructure including healthcare access. Within such places, historically and socially marginalized populations become invisible, are subject to the health effects of environmental hazards, and are limited depending on their positionality and thus vulnerability to healthcare services. • Municipal unincorporation contributes to health disparities among Latinx families in US-Mexico borderlands. • Latinx children in colonias are disproportionately exposed to environmental toxins. • Geography acts as a structural determinant of health for Latinx families in colonias. • A binational approach to health services should be prioritized for families in the borderlands. [ABSTRACT FROM AUTHOR]

Health insurance is one of the main financing mechanisms currently being used in low and middle-income countries to improve access to quality services. Tanzania has been running its National Health Insurance Fund (NHIF) since 2001 and has recently undergone significant reforms. However, there is limited attention to the causal mechanisms through which NHIF improves service coverage and quality of care. This paper aims to use a system dynamics (qualitative) approach to understand NHIF causal pathways and feedback loops for improving service coverage and quality of care at the primary healthcare level in Tanzania. We used qualitative interviews with 32 stakeholders from national, regional, district, and health facility levels conducted between May to July 2021. Based on the main findings and themes generated from the interviews, causal mechanisms, and feedback loops were created. The majority of feedback loops in the CLDs were reinforcing cycles for improving service coverage among beneficiaries and the quality of care by providers, with different external factors affecting these two actions. Our main feedback loop shows that the NHIF plays a crucial role in providing additional financial resources to facilities to purchase essential medical commodities to deliver care. However, this cycle is often interrupted by reimbursement delays. Additionally, beneficiaries' perception that lower-level facilities have poorer quality of care has reinforced care seeking at higher-levels. This has decreased lower level facilities' ability to benefit from the insurance and improve their capacity to deliver quality care. Another key finding was that the NHIF funding has resulted in better services for insured populations compared to the uninsured. To increase quality of care, the NHIF may benefit from improving its reimbursement administrative processes, increasing the capacity of lower levels of care to benefit from the insurance and appropriately incentivizing providers for continuity of care. • The NHIF influences service coverage and quality in complex ways. • NHIF reimbursement is crucial for facilities and its delay affects inputs for quality. • Lower levels of care benefit less from NHIF. • Need to improve reimbursement process to enhance quality of care. [ABSTRACT FROM AUTHOR]

This paper examines the impact of residence-based ethnic networks on mental health; such networks are defined as the concentration of residents from the same country of origin in a neighborhood. To estimate the effect, we utilize administrative registry data, together with data on quasi-random assignment of apartments to non-Western households with housing needs to various neighborhoods. After controlling for individual characteristics, time-invariant neighborhood characteristics, and general practitioners (GP) fixed effects, we find that a 1–percentage-point increase in the concentration of residence-based co-ethnics (RBCEs) increases the probability of being treated with psychiatric medications by 0.7-percentage point over a 5-year period after the assignment. With 19% of the population being treated with psychiatric medications the year before assignment, the result translates into an effect size of 3.7%. The results indicate that relatively high concentrations of co-ethnics treated with psychiatric medications increase the probability of being treated with psychiatric medications. The positive impact on treatment with psychiatric medication reflects an increase in the demand for these drugs when moving into a neighborhood with neighbors of the same ethnicity. If new residents are in good mental health condition when moving, these results suggest that moving into a neighborhood with a high co-ethic concentration worsens mental health status. However, as the population in this study is a vulnerable group an increase in treatment with psychiatric medications likely reflects that untreated mental health problems are treated, and the mental health status improved. The group of non-Western immigrants in this study differs significantly from the population in general, thus, results may not be generalized to all non-Western immigrants. • We study the impact of residence-based ethnic networks on mental health. • We utilize quasi-random assignment of immigrants in urgent housing needs. • Residence-based ethnic networks increase the use of psychiatric medication. • The characteristics of co-ethnic neighbors impact significantly mental health. [ABSTRACT FROM AUTHOR]

This paper examined the relationship between social identity and health-related behavior, exploring whether social identities are associated with multiple health-related behaviors or only specific ones, and whether this association varies on the type of social identity, the type of social identity measures or the expected relationship between identity and behavior. In a systematic review and meta-analysis we assessed whether the pattern of findings can be explained by the social identity approach. An extensive literature search was conducted in several databases including EBSCO-host and PubMed, using elaborate search terms related to social identity and health-related behavior. This resulted in 10728 potential articles, with 115 articles (with 248 effect sizes from 133 independent samples, N = 112.112) included in the meta-analysis. We found a small but positive overall association between social identification and health-related behavior, which was present for actual behavior, as well as for intention and attitudes. This association was stronger for health-related social identities, positive health-related behaviors, when the expected relationship was positive and when indirect social identity measures were used. However, not all findings could be explained by the social identity approach, indicating a need for further research to better understand the relationship between social identity and health-related behavior, in order to more effectively incorporate social identity into health interventions. • There's a positive association between social identity and health-related behavior. • This effect is present for actual behavior, intention and attitudes. • This effect is stronger for some social identities and health-related behavior. • These results can partly be explained by social identity approach. [ABSTRACT FROM AUTHOR]

A recent national survey of bereaved partners found high levels of complicated grief and psychological distress, with evidence that loneliness and isolation may contribute to these outcomes. However, the mechanisms of action for this have not been explored. To advance grief theory this paper reports analysis of the survey free-text data to examine the relationship between social support and emotional responses to bereavement. Individuals bereaved of a civil partner or spouse 6–10 months previously were identified through death registration data. 569/1945 (29 %) completed surveys were received. Of those, 311 participants (55 %) provided responses to two free-text questions which asked about their 'feelings since the death of their partner or spouse', and 'about the support around' them. Data were analysed using corpus-assisted discourse analysis and the discourse dynamics approach for figurative language. Participants described diverse emotional responses to the bereavement (e.g. sadness, anger, denial, acceptance), and the value of formal and informal bereavement support. Although many of the experiences described are accounted for in existing grief theory, some participants described a liminal experience not recognised within these theories. They felt trapped, unable to engage with loss or restoration, and unable to move forward as their planned future no longer existed. They sought out 'communitas' (solidarity in experiences), but often found support from their social networks had diminished. Metaphors were used to describe this liminality, with partner grief expressed as a dark agentic force, a monster, an abyss, and as water. The findings of this study offer original insights into experiences and trajectories of bereavement, and our understandings of prolonged or complicated grief. A novel model 'Between Loss and Restoration' is presented to include these experiences. Recognition of the place for liminality within the spectrum of grief experiences could enhance grief literacy and improve formal and informal bereavement support provision. • Bereaved partners exhibit a range of intense emotions 6–10 months after the loss. • Some bereaved partners describe feeling trapped between loss and restoration. • This liminal experience is characterised by a feeling of 'not being anywhere'. • Metaphors are used to construct the liminal state as a monster, an abyss and water. • 'Between Loss and Restoration' advances grief theory to include this liminal state. [ABSTRACT FROM AUTHOR]

This paper explores the impact of school food policy from the perspective of school food workers to offer an alternative account of why school food may not be having the desired impact on child health or food choices. Drawing upon the findings from an institutional ethnography carried out in three UK primary schools, we argue that school food is being asked to perform an unrealistic task of luring children and families away from more unhealthy food options, without being given adequate resources or powers to do this job effectively. We theorise that the narrative depicting school food as a hero, combatting the harms of poor dietary choices and poor health outcomes, is inappropriate as a countermeasure to mitigate the effects of wider food industry forces. We revisit the narrative to consider the power imbalances within society that structure dietary choices, presenting our findings and the wider policy review in the form of a story about the evolution of school food set against a shifting food environment. We conclude with recommendations for policy makers who want to see school food have a greater impact in improving child health. • We report on an Institutional Ethnography of 3 UK schools to explore the issue of low meal uptake. • Semi-structured interviews with food workers, observations, and text analysis were used. • A significant barrier to meal uptake was an unfamiliarity with the healthy food offered in schools. • We discuss the evolution of the UK school meal service alongside changes in the wider food system. • We propose policy changes that would strengthen the protected food space offered by schools. [ABSTRACT FROM AUTHOR]

This paper presents a critical analysis of newspaper articles (N = 60) published in a leading vernacular newspaper about violence against doctors in India. Adopting a theoretical perspective that considers 'news as a cultural practice,' a qualitative content analysis was conducted to examine how the phenomenon is framed and presented in the news, i.e., what is problematized, what causal links are drawn or hinted at, what moral stance is taken or alluded to, and what solutions are proffered and why, to arrive at a nuanced understanding of various aspects of this social phenomenon. Three overlapping key themes emerged from the analysis, namely the narrative of victimization, the changing doctor-patient relationship, and the crisis facing the 'noble profession' of medicine. It reveals how the media shapes public opinion and attitudes towards the state of the medical profession while in turn, reflecting existing opinions, attitudes, and cultural values; the analysis also reveals missing perspectives such as the voices of the patients and the public. We highlight how the findings are not merely the dominant ways in which the rise in incidents of violence against doctors is reported and is understood in society, but how media might have shaped the popular discourse around the issue and why. We reflect on what the reportage says about the state of the medical profession and its standing in society in India. • The rise in violence against doctors in India has received much media coverage. • The coverage suggests that the doctor-patient relationship is under stress. • Doctors feel that they are being unfairly targeted and being treated unjustly. • A re-configuration of the social contract between doctors and society is needed. • Such reconfiguration is underway in some form in many countries across the world. [ABSTRACT FROM AUTHOR]

Since the approvals of several vaccines against COVID-19 by the World Health Organization, a large body of research has studied the determinants of individuals' intention to be vaccinated against COVID-19 in a variety of societies. Vaccine intention is a complex construct rooted in the social context that informs the decision-making process. The underlying reasons for older adults' intention to receive the vaccination is even more important to health authorities in societies with large proportions of older adults. In this paper, we interview 27 women over age 55 in Singapore about their COVID-19 vaccine decision-making. Using a social-ecological framework of trust, we identify factors at both individual and institutional levels that build or undermine trust and underlie older women's decisions to receive COVID-19 vaccinations in an authoritarian regime. Findings show that both interpersonal trust and institutional trust contribute to vaccine uptake, however, trust can also contribute to delays in vaccination. Moreover, a sizable minority of respondents report that they were vaccinated not because of institutional trust, but because they felt compelled to do so. The results shed light on directions for future vaccination campaigns. • We focus on older women in an authoritarian state. • We adopt a social-ecological framework of trust. • Both interpersonal trust and institutional trust contribute to vaccine uptake as well as delays in vaccination. • This study provides policy implications for future vaccination campaigns. [ABSTRACT FROM AUTHOR]

In the context of the escalating burden of diabetes in low and middle-income countries (LMICs), there is a pressing concern about the widening disparities in care and outcomes across socioeconomic groups. This paper estimates health poverty measures among individuals with type 2 diabetes mellitus (T2DM) in Malaysia. Using data from the National Diabetes Registry between 2009 and 2018, the study linked 932,855 people with T2DM aged 40–75 to death records. Cox proportional hazards models were used to estimate the 5-year survival probabilities for each patient, stratified by age and sex, while controlling for comorbidities and area-based indicators of socio-economic status (SES), such as district-level asset-based indices and night-time luminosity. Measures of health poverty, based on the Foster-Greer-Thorbecke (FGT) measures, were employed to capture excessive risk of premature mortality. Two poverty line thresholds were used, namely a 5% and 10% reduction in survival probability compared to age and sex-adjusted survival probability of the general population. Counterfactual simulations estimated the extent to which comorbidities contribute to health poverty. 43.5% of the sample experienced health poverty using the 5% threshold, and 8.9% were health poor using the 10% threshold. Comorbidities contribute 2.9% for males and 5.4% for females, at the 5% threshold. At the 10% threshold, they contribute 7.4% for males and 3.4% for females. If all patients lived in areas of highest night-light intensity, poverty would fall by 5.8% for males and 4.6% for females at the 5% threshold, and 4.1% for males and 0.8% for females at the 10% threshold. In Malaysia, there is a high incidence of health poverty among people with diabetes, and it is strongly associated with comorbidities and area-based measures of SES. Expanding the application of health poverty measurement, through a combination of clinical registries and open spatial data, can facilitate simulations for health poverty alleviation. • Novel health poverty measures applied to T2DM in Malaysia using early mortality risk. • Administrative dataset comprising 1M adults combined with death records and SES. • Male gender, older age and area deprivation drive health poverty. • Nighttime luminosity reveals regional patterns in health poverty. • Combining luminosity data and medical datasets enhances risk stratification in LMICs. [ABSTRACT FROM AUTHOR]

Colorectal cancer (CRC) screening continues to be underutilized in the US despite the availability of multiple effective, guideline-recommended screening options. Provider recommendation has been consistently shown to improve screening completion. Yet, available literature provides little information as to how specific information providers communicate influence patient decision-making about CRC screening. We tested the pathways through which information communicated by providers about the "Why" and "How" of CRC screening using the mt-sDNA test contributes to intention to complete the test. Data came from a behavioral theory-informed survey that we developed to identify psychosocial factors associated with mt-sDNA screening. RTI International administered the survey between 03/2022-06/2022 to a sample of US adults ages 45–75 who received a valid order for mt-sDNA screening with a shipping date between 5/2021-9/2021. Participants completed an electronic or paper survey. We tested the proposed relationships using structural equation modeling and tested indirect effects using Monte Carlo method. A total of 2,973 participants completed the survey (response rate: 21.7%) and 81.6% (n = 2,427) reported have had a conversation with their health care provider about mt-sDNA screening before the test was ordered. We found that "Why" information from providers was positively associated with perceived effectiveness of mt-sDNA screening, while "How" information was positively associated with perceived ease of use. "Why" information contributed to screening intention through perceived effectiveness while "How" information contributed to screening intention through perceived ease of use. These findings emphasize the critical role of provider communication in shaping patient decision-making regarding CRC screening. CRC screening interventions could consider implementing provider-patient communication strategies focusing on improving patient understanding of the rationale for CRC screening and the effectiveness of available screening options as well as addressing barriers and enhancing patients' self-efficacy in completing their preferred screening option. • Survey on how provider communication contributes to mt-sDNA screening intention. • "Why" information from providers improves perceived effectiveness of screening. • "How" information from providers improves perceived ease of use of screening. • "Why" information contributes to screening intention via perceived effectiveness. • "How" information contributes to screening intention via perceived ease of use. [ABSTRACT FROM AUTHOR]

Although operating an emergency department (ED) can influence general admission activity of hospitals, most articles that analyze hospital care ignore the potential spillover of emergency activity. In this paper, we examine the consequences of a French reform that encouraged the creation of EDs within private-for-profit (PFP) hospitals in order to decrease congestion in EDs. We use administrative panel data on 365 French PFP hospitals observed between 2002 and 2012. Specifications including hospital fixed-effects are estimated to examine the impact of an ED opening on private hospitals' admission activity, namely inpatient and day-care admissions (ED visits are excluded, but patients admitted following an ED visit are included). We control for shocks that can impact demand for care in hospitals, and we estimate yearly changes before and after the opening. We find that an ED opening is followed by an increase in the number and proportion of inpatient admissions, and by an increase in the length of inpatient stays. A transitory increase in the bed occupancy rate is also observed. In many countries, public and private hospitals compete to some extent. The former provide a public service, while the latter are profit-maximizers that are allowed to specialize in profitable activities. They generally focus on day-care admissions. We provide empirical evidence that private hospitals experience a significant change in the composition of their admissions when they start providing emergency care. Opening an ED creates a new non-selective entryway to private hospitals, resulting in admissions of inpatients with health problems that are more severe. Hence, involving PFP hospitals in the provision of emergency care is likely to make the structure of admissions of private hospitals closer to that of public hospitals. • Financial incentives encouraged the creation of EDs among French private hospitals. • Starting up emergency care spills over to private hospital admissions. • ED opening increases hospital's proportion and length of inpatient admissions. • Results suggest higher severity of patients' conditions after opening. • Structure of stays in private and public hospitals gets more similar after ED opening. [ABSTRACT FROM AUTHOR]

Socioeconomic status (SES) is a robust correlate of mental health, and emerging research indicates that life course trajectories of SES (i.e., social mobility) may be more predictive for health outcomes than point-in-time SES assessments. This paper presents five primary meta-analyses to determine how mental health differs between social mobility groups. We conducted a systematic review of PsycINFO, Web of Science, and PubMed for studies of social mobility and mental health. We used random-effects multilevel meta-analyses to compare mental health problems between individuals who experienced upward mobility, downward mobility, stable high SES, and stable low SES. We included data from 21 studies and 157,763 unique participants yielding 105 effect sizes. Upwardly mobile participants experienced more mental health problems than stable high SES participants (d = 0.11), fewer mental health problems than stable low SES participants (d = −0.24), and fewer mental health problems than downwardly mobile participants (d = −0.17). Downwardly mobile individuals experienced more mental health problems than stable high SES participants (d = 0.26) and fewer mental health problems than stable low SES participants (d = −0.10). Subgroup analyses revealed that the magnitude of effects did not differ by continent of study, type of generational mobility (intergenerational vs. intragenerational), or SES indicator. Meta-regressions with continuous moderators (age, gender, race, study quality) were also non-significant. Taken together, these results indicate that both upwardly and downwardly mobile individuals experience more mental health problems than those who are persistently advantaged, and they both experience fewer mental health problems than those who are persistently disadvantaged. Our findings suggest that while current SES has a stronger association with adult mental health than childhood SES, it is important to also consider the impact of early life and prior generation SES to account for lingering effects of early disadvantage. • Social mobility has small but significant effects on subsequent mental health. • The socially mobile have more mental health problems than the always-advantaged. • The socially mobile have fewer mental health problems than the always-disadvantaged. • Current social class influences mental health more than early life social class. • Early life social class still has some lingering consequences for mental health. [ABSTRACT FROM AUTHOR]

A rising emphasis on patient involvement in clinical research and healthcare improvement has led to the steady incorporation of patients and caregivers into this work. However, interactional factors shaping recruitment processes are not well understood. In this paper, we present a qualitative analysis of interviews with twenty-six patients, family members, engagement staff and healthcare providers who are engaged in healthcare improvement work in the United States. We focus on how stakeholders account for recruitment decisions to participate in healthcare improvement work. We find that expressions of and judgments about patients' and caregivers' cultural health capital shape providers' decisions to extend invitations to participate in healthcare improvement work. These findings extend current conceptualizations of cultural health capital beyond the clinical encounter to reveal factors shaping patient recruitment into healthcare improvement work. In theorizing how cultural health capital shapes action in this new setting, we found that healthcare providers, engagement staff, and patients/caregivers attended to different aspects of cultural health capital when accounting for why they extended or received a recruitment pitch. We further found that participating in healthcare improvement work led to a boost in cultural health capital for patients and caregivers, which they could use to develop transmissible forms of cultural health capital for less centrally involved patients and caregivers. Finally, we describe how participants in healthcare improvement collaboratives account for a lack of diversity among partners. These findings help us hypothesize the consequences of recruitment processes that rely on displays and judgments of cultural health capital and identify possibilities for change. Using the case of healthcare improvement work in Collaborative Learning Health Systems, our findings advance past work on cultural health capital in medical sociology by theorizing the role of cultural health capital in recruitment processes. • Providers recruit patients for healthcare improvement work with subjective criteria. • Providers often recruit high-resourced, privileged patients that they "vibe" with. • Partners build cultural health capital from doing healthcare improvement work. • Recruiting for cultural health capital may exclude patients from diverse backgrounds. • The role of recruitment should be considered to improve partner representation. [ABSTRACT FROM AUTHOR]