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This paper examines the experiences of adolescents from mixed migratory status families affected by deportation. We analyze the impacts on their mental and emotional health when they are separated from one parent in the United States, forcibly displaced with another to Oaxaca, and experience the consequences of their deportation in Mexico. We use a qualitative and ethnographic methodology. This paper focuses on data from semi-structured interviews and focus groups with 15 parents who had been deported from the United States and 53 adolescents who moved with them to Mexico. The data was collected between 2018 and 2020. The main findings show the existence of emotions that are sustained in the transnational flow and acquire new nuances upon return. They also show the emergence of new conditions related to family separation, all of which have an impact on the adolescents' well-being and on important areas of their lives, such as education. The research contributes to knowledge in two main ways: 1) it addresses the impacts of parental deportation on the well-being of adolescents in mixed-status families, which have typically focused on children; 2) it studies how parental deportation affects the mental and emotional health of adolescents de facto deported to Mexico, a field still little studied. • De facto deportation has mental health consequences among adolescents. • The forced nature of de facto deportation produces helplessness, aggression and anger. • The code of silence associated with deportation generates fear, stress, anxiety. • Ambiguous loss is accentuated at important moments in academic and developmental life. • Family separation and de facto deportation affect school performance. [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 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]

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]

Medical students with chronic health conditions are an underrepresented and often overlooked population in medical education. Previous research describes the dual roles they hold as both healthcare recipients and providers and details challenges they face related to accommodations and accessibility. However, less is known about how having a chronic health condition shapes the day-to-day aspects of medical education. To address this gap in knowledge, I conducted semi-structured interviews with eighteen medical students with chronic conditions and examined data using reflexive thematic analysis. Findings revealed the competing demands students face between medical school expectations and the need to manage their health. They work to reconcile these demands using tools like accommodations and strategic communication and by reconstructing narratives to re-assess self-imposed expectations. These participants understand having a chronic health condition as just one piece of their larger sense of self. Participants approach this understanding in individualized and nuanced ways, yet all share a cohesive view that their experiences having chronic health conditions inform their medical practice for the better through the development of genuine empathy for patients. This paper concludes with recommendations drawn from participant interviews of how medical schools can better support students with chronic health conditions. • Chronic condition management and medical training compete for time and energy. • Demands are reconciled at structural, interpersonal, and intrapersonal levels. • Having a chronic condition influences but does not define medical training. • First-hand healthcare experiences build genuine empathy and improve patient care. [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]

Abstract: In recent years, Kazakhstan has become an important destination for primarily undocumented seasonal workers from Uzbekistan. In a context of high tuberculosis (TB) incidence, TB treatment is provided free for all residents in Kazakhstan, but migrants rarely access these services. This paper reports findings from a qualitative study conducted with migrants, TB patients and health care workers between July and September 2008 to understand the mechanisms that impede migrants’ access to care. Findings describe three structural contexts – the employment, legal and health care contexts – which act in concert to render migrants vulnerable to exploitative work conditions and cause a series of barriers to health care. These conditions contribute to increased exposure to TB, heightened risk of reactivation due to weakened immunity, treatment-seeking delays, and increased severity of disease. Seasonal migration patterns also contribute to treatment interruption, which constitutes a risk for the creation of drug resistance. Using the theory of structural violence coupled with the concept of cumulative vulnerability, this paper analyzes how illegality interacts with exploitation and social marginalization to produce vulnerability to TB and restrict access to treatment. [Copyright &y& Elsevier]

Following the successful development of vaccines for COVID-19, attention turned to the problem of vaccine access. However, in contexts where vaccines are available, hesitancy remains a major problem. Informed theoretically by the scholarship on vaccine anxiety, this paper uses a qualitative research approach that included 144 semi-structured interviews to investigate how social and political dynamics shaped people's perspectives in particular environments in Ghana, Cameroon, and Malawi about COVID-19's viral spread and COVID-19 vaccines. Vaccines and the viral spread of COVID-19 are related to political tensions and class-related fractures in particular contexts, and how the public interprets COVID-19's viral spread and engages with vaccination is based on people's social and political environment and their experience. Subjectivities are also rooted in coloniality. Vaccine confidence goes beyond clinical and regulatory authority approvals, and encompasses forces that are economic, social, and political in nature. Thus, an exclusive focus on technical prescriptions for enhancing vaccine uptake will not achieve significant positive results. • Vaccines are related to political tensions and class-related fractures in particular settings. • Political context shapes how people view mandatory vaccination. • The body is a mirror of socio-political context. • Worries about getting COVID-19 vaccines cut across professional and income-related categories. • Distrust in vaccines has national and international dimensions. [ABSTRACT FROM AUTHOR]

Abstract: The process of designing and developing discrete choice experiments (DCEs) is often under reported. The need to adequately report the results of qualitative work used to identify attributes and levels used in a DCE is recognised. However, one area that has received relatively little attention is the exploration of the choice question of interest. This paper provides a case study of the process used to design a stated preference survey to assess youth preferences for integrated sexual and reproductive health (SRH) and HIV outreach services in Malawi. Development and design consisted of six distinct but overlapping and iterative stages. Stage one was a review of the literature. Stage two involved developing a decision map to conceptualise the choice processes involved. Stage three included twelve focus group discussions with young people aged 15–24 (n = 113) and three key informant interviews (n = 3) conducted in Ntcheu District, Malawi. Stage four involved analysis of qualitative data and identification of potential attributes and levels. The choice format and experimental design were selected in stages five and six. The results of the literature review were used to develop a decision map outlining the choices that young people accessing SRH services may face. For youth that would like to use services two key choices were identified: the choice between providers and the choice of service delivery attributes within a provider type. Youth preferences for provider type are best explored using a DCE with a labelled design, while preferences for service delivery attributes associated with a particular provider are better understood using an unlabelled design. Consequently, two DCEs were adopted to jointly assess preferences in this context. Used in combination, the results of the literature review, the decision mapping process and the qualitative work provided robust approach to designing the DCEs individually and as complementary pieces of work. [Copyright &y& Elsevier]

Abstract: In England from 2002 to 2013, Primary Care Trusts (PCTs) were responsible for commissioning healthcare for their local populations. The NHS has recently undergone rapid organisational change whereby clinicians have assumed responsibility for local commissioning decisions. This change in commissioning arrangements alongside the current financial pressures facing the NHS provides an impetus for considering the use of technical prioritisation methods to enable the identification of savings without having a detrimental effect on the health of the population. This paper reports on the design and implementation of a technical prioritisation method termed PBMA applied within NHS Plymouth, an English PCT responsible for commissioning services for a population of approximately 270,000. We evaluated the effectiveness of the process, the extent to which it was appropriate for local healthcare commissioning and whether it identified budget savings. Using qualitative research methodology, we found the process produced clear strategic and operational priorities for 2010/11, providing staff with focus and structure, and delivered a substantial planned reduction in hospital activity levels. Participants expressed satisfaction with the process. NHS Plymouth adhered to the PBMA process, although concerns were raised about the evidence for some priorities, decibel rationing, and a lack of robust challenge at priority-setting meetings. Further work is required to enhance participants' understanding of marginal analysis. Participants highlighted several external benefits, particularly in terms of cultural change, and felt the process should encompass the whole local health and social care community. This evaluation indicates that the prioritisation method was effective in producing priorities for NHS Plymouth, and that PBMA provides an appropriate method for allocating resources at a local level. In order for PBMA to identify savings, cultural and structural barriers to disinvestment must be addressed. These findings will interest other healthcare commissioners in developing their own approaches to priority-setting. [Copyright &y& Elsevier]

Abstract: Access to transport is an important determinant of health, and concessionary fares for public transport are one way to reduce the ‘transport exclusion’ that can limit access. This paper draws on qualitative data from two groups typically at risk of transport exclusion: young people (12–18 years of age, n = 118) and older citizens (60+ years of age, n = 46). The data were collected in London, UK, where young people and older citizens are currently entitled to concessionary bus travel. We focus on how this entitlement is understood and enacted, and how different sources of entitlement mediate the relationship between transport and wellbeing. Both groups felt that their formal entitlement to travel for free reflected their social worth and was, particularly for older citizens, relatively unproblematic. The provision of a concessionary transport entitlement also helped to combat feelings of social exclusion by enhancing recipients' sense of belonging to the city and to a ‘community’. However, informal entitlements to particular spaces on the bus reflected less valued social attributes such as need or frailty. Thus in the course of travelling by bus the enactment of entitlements to space and seats entailed the negotiation of social differences and personal vulnerabilities, and this carried with it potential threats to wellbeing. We conclude that the process, as well as the substance, of entitlement can mediate wellbeing; and that where the basis for providing a given entitlement is widely understood and accepted, the risks to wellbeing associated with enacting that entitlement will be reduced. [Copyright &y& Elsevier]

Abstract: The MANAS trial evaluated the effectiveness of a lay counselor led collaborative stepped care intervention for Common Mental Disorders (CMD) in public and private sector primary care settings in Goa, India. This paper describes the qualitative findings of the experience of the intervention and its impact on health and psychosocial outcomes. Twenty four primary care facilities (12 public and private each) were randomized to provide either collaborative stepped care (CSC) or enhanced usual care (EUC) to adults who screen positive for CMDs. Participants were sampled purposively based on two criteria: gender and, in the CSC arm, adherence with the intervention. The qualitative study component involved two semi-structured interviews with participants of both arms (N = 115); the first interview within 2 months of recruitment and the second 6–8 months after recruitment. Data were collected between September 2007 and November 2009. More participants in the CSC than EUC arm reported relief from symptoms and an improvement in social functioning and positive impact on work and activities of daily life. The CSC participants attributed their improvement both to medication received from the doctors and the strategies suggested by the lay Health Counselors (HC). However, two key differences were observed in the results for the two types of facilities. First, the CSC participants in the public sector clinics were more likely to consider the HCs to be an important component of providing care who served as a link between patient and the doctor, provided them skills on stress management and helped in adherence to medication. Second, in the private sector, doctors performed roles similar to those of the HCs and participants in both arms placed much faith in the doctor who acted as a confidante and was perceived to understand the participant's health and context intimately. Lay counselors working in a CSC model have a positive effect on symptomatic relief, social functioning and satisfaction with care in patients with CMD attending primary care clinics although the impact, compared with usual care, is greater in the public sector. [Copyright &y& Elsevier]

Abstract: This paper presents findings from a qualitative study designed to explore the reasons why some Papua New Guineans who own mosquito nets choose not to use them, whether on a regular or episodic basis. In-depth interviews (IDIs) were conducted with a sub-sample (n = 44) of participants in a country wide household survey who reported owning or having access to a mosquito net, but not having slept under a mosquito net the night prior to survey. All IDIs were completed between December 2010 and June 2011. Analysis was informed by a general inductive methodology. Multiple impediments to regular mosquito net use were identified by study participants, although all were broadly grouped into the inter-related categories of net-, environmental- or human-factors. Indifference emerged as the most influential impediment towards regular net use presenting as a general attitudinal context in which a majority of participant responses were grounded. A lack of knowledge regarding malaria transmission pathways or the utility of mosquito nets did not appear to underlie this indifference. Rather, the indifference appeared to be rooted in a lack of fear of malaria infection cultivated through lived experience. A wide range of interventions could potentially promote greater mosquito net use amongst this population. However, the basis of any intervention strategy, given the pervasive indifferent attitude towards regular mosquito net use, should be to render individual mosquito net use as easy and as convenient as possible and to promote complementary malaria control strategies where appropriate. [Copyright &y& Elsevier]

Abstract: The paper discusses the possibilities technology provides for (re-)shaping healthcare professionals. Drawing upon critical studies of technology and the sociology of professionals, we present findings from a longitudinal study into the introduction of the Electronic Prescription Service (EPS) in Community Pharmacies in England conducted between June 2009 and July 2011. Our case illustrates the conditions that allow technology to shape healthcare professionals and the potential consequences of such shaping. The data collected, which consisted of qualitative interviews and document analysis, and their analysis rests on predictions of future directions and developments of the pharmacy profession through EPS. Specifically, we show that technology has the potential to shape fundamental aspects of pharmacy work such as its nature and values, professional roles, the degree of power professionals can exercise, their jurisdictions and professional boundaries. Drawing upon these changes and on their implications, we argue that the introduction of technology in a healthcare setting does not determine consequences but opens up a field in which processes of de-professionalisation and re-professionalisation occur simultaneously. Their implications for healthcare professionals in the future, remains an open, yet worth exploring, question for the present. [Copyright &y& Elsevier]

Abstract: This paper reports findings from an evaluation of the local implementation of a procedural public health programme whose objective is to create healthy environments (HE) for vulnerable families in the province of Quebec (Canada) through the funding of local projects. Considering the potential issue of programme–context interaction, our research question was the following: Does the procedural nature of this HE programme result in variation between local cases in terms of the types of projects and collaborations it subsidizes? Given that the creation of healthy environments requires intersectoral health action to address social determinants of health, the data were analysed with respect to intersectorality and cooperation. Results of this qualitative multiple case study (n = 8), for the period 2004–2009, show that the majority of subsidized projects were in the health and social services sector and focused on parenting, parent–child attachment, nutrition and the social networks of families. Only a few initiatives reached beyond the health and social services sector to address social health determinants such as education, housing and transportation. Membership and mandates of the local groups responsible for programme implementation also showed little intersectorality. The limited variation between these eight cases can be attributed to the configuration of the local networks, as well as to specific issues in urban and rural areas. To explain the overall similarity of results across cases, we turned to the literature on policy instruments which suggests that particular characteristics of a programme may produce effects that are independent of its intended objective. In our study, several programme mechanisms, such as those framing the definition of «healthy environment» and budget management rules, could have encouraged the local development of initiatives that focus on individual skills related to parenting and attachment rather than the development of intersectoral health action to address social determinants of health. [Copyright &y& Elsevier]

Abstract: Using data from 89 American Indian adolescents and guided by the Network Episode Model, this paper analyses pathways to residential substance abuse treatment and their correlates. These adolescents were recruited at admission to a tribally-operated substance abuse treatment program in the southern United States from October 1998 to May 2001. Results from the qualitative analyses of these adolescent''s pathways to care narratives indicated that 35% ultimately agreed with the decision for their entry into treatment; 41% were Compelled to enter treatment by others, usually by their parents, parole officers, and judges; and 24% did not describe a clear pathway to care. In the multinomial logistic regression model examining correlates of these pathways to care classifications, adolescents who described pathways indicative of agreement also reported greater readiness for treatment than the adolescents who described compelled or no clear pathways to care. Adolescents who described a Compelled pathway were less likely to meet diagnostic criteria for Conduct Disorder and described fewer social network ties. We were unable to find a relationship between pathways classifications and referral source, suggesting these narratives were subjective constructions of pathways to care rather than a factual representation of this process. In the final logistic regression model examining correlates of treatment completion, articulating a pathway to care, whether it was one of agreement or of being compelled into treatment, predicted a greater likelihood of completing treatment. Overall, these narratives and their correlates are highly consistent with the Network-Episode Model''s emphasis on the interaction of self, situation, and social network in shaping the treatment seeking process, demonstrating the applicability of this model to understanding the treatment seeking process in this special population and suggests important considerations for understanding the dynamics of service utilization across diverse communities. [Copyright &y& Elsevier]

Despite widespread acknowledgement of internet use for information about health, patients report not disclosing use of online health information in consultations. This paper compares patients' reported use of the internet with matched video recordings of consultations. The concepts of doctorability and epistemics are employed to consider similarities and differences between patients' reports in interviews and actions in the consultation. Data are drawn from the Harnessing Resources from the Internet study conducted in the UK. The data set consists of 281 video-recorded general practice consultations, with pre-consultation questionnaires completed by all patients, interviews with all 10 participating doctors and 28 selected patients. We focus on the 28 patient interviews and associated consultation recordings. A conversation analytic (CA) approach is used to systematically inspect both the interview and consultation data. In interviews patients presented use of the internet as associated with appropriate self-management and help-seeking. In consultations patients skilfully translated what they had found on the internet in order to provide grounds for the actions they sought. We conclude that patients translate and utilise what they have found on the internet to assert the doctorability of their presenting problems. Furthermore, patients design their talk in both interviews and consultations to accord with their understanding of the epistemic rights of both doctors and patients. Patients search the internet so they are informed about their medical problem, however they carefully manage disclosure of information to avoid disrupting the smooth running of medical interactions. • Patients seek information from the internet to support decisions to consult. • Patients seek information from the internet to support appropriate self-management. • Patients skilfully translate what they find on the internet to support requests. • Patients skilfully use the internet to invite action from their doctors. • Patients do not openly challenge the epistemic authority of the doctor. [ABSTRACT FROM AUTHOR]

This paper investigates the impact of the Stepping Stones Creating Futures (SSCF) intervention on young women in informal settlements in eThekwini, South Africa. Specifically, whether following participation in the intervention the young women experienced a reduction in intimate partner violence, strengthened agency and shifted gender relations. Where changes occurred, it examines how they occurred, and barriers and enablers to change. SSCF is a gender transformative and livelihoods strengthening intervention using participatory, reflective small groups. Qualitative research was undertaken with fifteen women participating in the SSCF randomised control trial between 2015 and 2018. The women were followed over 18 months, participating in in-depth interviews at baseline, 12- and 18-months post intervention. To supplement these, eight women were involved in Photovoice work at baseline and 18 months and seven were included in ongoing participant observation. Data were analysed inductively. Data revealed many women changed their behaviours following SSCF, including: having more power within relationships, improved communication and relationship skills, increased resistance to controlling partners, shifting relationship expectations, emergence of new femininities and improved livelihoods. Despite these important shifts many women did not report a reduction in IPV. Nonetheless we argue most of the women, following the intervention, became more agentic. Drawing on the notion of 'distributed agency' as developed by Campbell and Mannell (2016), we show that SSCF bolstered the women's distributed agency. Distributed agency recognizes small agentic acts that women take, acts which to them are significant, it further notes that agency is temporal, fluid, dynamic and context specific. Women do not 'either have agency or not', rather being agentic depends on time, context and the particular incident. These findings provide an important contribution to the limited application of distributed agency and femininities work in informal settlements and are critical for policy and intervention science to reduce IPV and support women's agency. • South African informal settlements have high rates of intimate partner violence. • The Stepping Stones Creating Futures intervention strengthened young women's agency. • Women developed new skills, reduced violent confrontations and improved livelihoods. • However, many women remained in violent relationships. • Participatory, group-based, gender transformative interventions can reduce violence. [ABSTRACT FROM AUTHOR]