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Abstract Background Process evaluations are increasingly integrated into randomised controlled trials (RCTs) of complex interventions to document their delivery and interactions with local systems and dynamics, helping understand observed health outcomes. Yet process evaluations often struggle to assess relevant contextual determinants, leaving much of the important role of “context” in shaping an intervention’s mechanisms opaque in many studies. A lack of easily adapted data collection methods to help define and operationalise indicators of context likely contributes to this. Methods We present a method to help structure measures of context in process evaluations and describe its use in two very different settings. The “Context Tracker” is an innovative tool for use within trials and quasi-experiments to more systematically capture and understand key dimensions of context. It was developed in Zimbabwe as part of a cluster randomised controlled trial and then adapted for a quasi-experimental evaluation in the UK. Both studies provided harm reduction and health services for marginalised and hard-to-reach populations. Results We developed the Context Tracker to be both standardised (i.e. formatted and applied in the same way across study sites) and flexible enough to allow unique features to be explored in greater detail. Drawing on the Context and Implementation of Complex Interventions (CICI) and Risk Environments frameworks, we mapped 5 domains across micro, meso and macro levels in a simple table and used existing evidence and experience to predict factors likely to affect delivery of and participation in intervention components. We tracked these over time across study sites using routine programme statistics, observation and qualitative methods. The Context Tracker enables identification and comparison of facilitators and barriers to implementation, variations in engagement with interventions, and how mechanisms of action are (or are not) triggered in different settings. Conclusions The Context Tracker is one example of how evidence-based contextual determinants can be used to guide data collection and analysis within process evaluations. It is relevant in low- and high-income settings and applicable to both qualitative and quantitative analyses. While perhaps most useful to process evaluations of complex interventions targeting marginalised communities, the broader approach would benefit a more general research audience.

Considering the persistence of significant health inequities in India, exploring the interface between health equity and social work education is a critical research priority. This article attempts to present a systematic analysis of the present status of health equity and social work training in India, elaborating on healthcare discrepancies among various populations in India, examining reasons for elevated morbidity and mortality rates among marginalized communities, and approaches to social work education at present. Consequently, curriculum revision should be all-inclusive and focus on highlighting fairness in health provision as well as cultural competency with an emphasis on social justice. It also calls for a paradigm shift towards contextualized knowledge, critical pedagogy and community engagement to prioritize health equity by suggesting that future training should focus on a holistic approach to dealing with preventable illnesses emanating from these determinants. In conclusion, this article points out the significance of giving more attention towards health equity within Indian schools of social work while providing some directions for possible research lines.

Abstract Objective: Water plays a critical role in the production of food and preparation of nutritious meals, yet few studies have examined the relationship between water and food insecurity. The primary objective of this study, therefore, was to examine how experiences of household water insecurity (HWI) relate to experiences of household food insecurity (HFI) among a pastoralist population living in an arid, water-stressed region of northern Kenya. Design: We implemented the twelve-item Household Water Insecurity Experiences (HWISE, range 0–36) Scale and the nine-item Household Food Insecurity Access Scale (HFIAS, range 0–27) in a cross-sectional survey to measure HWI and HFI, respectively. Data on socio-demographic characteristics and intake of meat and dairy in the prior week were collected as covariates of interest. Setting: Northern Kenya, June–July 2019. Participants: Daasanach pastoralist households (n 136) from seven communities. Results: In the prior 4 weeks, 93·4 % and 98·5 % of households had experienced moderate-to-severe HWI and HFI, respectively. Multiple linear regression analyses indicated a strong association between HWI and HFI. Each point higher HWISE score was associated with a 0·44-point (95 % CI: 0·22, 0·66, P = 0·003) higher HFIAS score adjusting for socio-economic status and other covariates. Conclusions: These findings demonstrate high prevalence and co-occurrence of HWI and HFI among Daasanach pastoralists in northern Kenya. This study highlights the need to address HWI and HFI simultaneously when developing policies and interventions to improve the nutritional well-being of populations whose subsistence is closely tied to water availability and access.

The use of administrative health data for research, monitoring, and quality improvement has proliferated in recent decades, leading to improvements in health across many disease areas and across the life course. However, not all populations are equally visible in administrative health data, and those that are less visible may be excluded from the benefits of associated research. Socially excluded populations -- including the homeless, people with substance dependence, people involved in sex work, migrants or asylum seekers, and people with a history of incarceration -- are typically characterised by health inequity. Yet people who experience social exclusion are often invisible within routinely collected administrative health data because information on their markers of social exclusion are not routinely recorded by healthcare providers. These circumstances make it difficult to understand the often complex health needs of socially excluded populations, evaluate and improve the quality of health services that they interact with, provide more accessible and appropriate health services, and develop effective and integrated responses to reduce health inequity. In this commentary we discuss how linking data from multiple sectors with administrative health data, often called cross-sectoral data linkage, is a key method for systematically identifying socially excluded populations in administrative health data and addressing other issues related to data quality and representativeness. We discuss how cross-sectoral data linkage can improve the representation of socially excluded populations in research, monitoring, and quality improvement initiatives, which can in turn inform coordinated responses across multiple sectors of service delivery. Finally, we articulate key challenges and potential solutions for advancing the use of cross-sectoral data linkage to improve the health of socially excluded populations, using international examples.

In the Soviet period, the incidence of venereal diseases (VDs)2 was ideologically interpreted by authorities as a deficiency inherent in capi- talist countries. It was stated that VDs would be eliminated in the Soviet Union at the earliest possible date. Compared to the independent Republic of Latvia (1918–1940), during the Soviet period, despite a larger popu- lation, the number of registered VDs infected patients was significantly lower. In such a historical context, a strange ideological obsession could be observed in the activities pursued by Soviet authorities when fighting VDs. The notion of the VDs as a remnant of the capitalist system determined the treatment of Soviet citizens infected by the VDs as marginalised populations. In order to achieve the goal of becoming a country where the VDs were eliminated, the Soviet Union practised a drastic dispensarisation system in the treatment of VDs, which was focused only on certain groups of the population that were identified in the documents of internal use for the fight against VDs. Starting with the 1960s, the VDs fighting policy also included the fight against prostitution, euphemised as the fight against “frivolous women”, by directing the control against the female gender. At the same time, the decisions at the highest level of the Soviet government, that were mostly marked by the “not to be published” stamp, formally corresponded to the ideas of gender equality and Soviet ideas of rule of law. In the context of the marginalised populations, authorities were of the opinion that it was justifiable to humiliate citizens, who would be forced to undergo unjustified medical examination, because the smallest proportion of marginalised populations, who were subjected to forced medical examination, turned out to be VDs positive. When assessing the extension of such prac- tices to the wider population, it was recognised that this would not contrib- ute to the strengthening of the Soviet rule of law. The purpose of the article is to reveal the development of the population categorisation practice in the context of the VDs fighting policy in the Latvian SSR.

We introduce and reflect on the benefits of a game developed from a qualitative study of general practice reception processes undertaken in two New Zealand (NZ) cities. In this research, we elicited the views of receptionists, practice managers, and individuals marginalised by health care processes (‘patients’). Data collection followed an iterative process, beginning with receptionists, then ‘patients’, then managers, and returning to receptionists. Consistent with best-practice research in NZ, Māori were involved in all phases of the field research in multiple roles: as advisors, researchers, and participants. The study was informed by critical theory and employed thematic analysis. We describe how we translated the findings into a format accessible for health care teams through the creation a board game. This game, modelled on the children's game ‘Snakes and Ladders’, exposes the ‘rules’ of general practice engagement when players adopt the roles of typical patient identities encountered in the study and try to ‘achieve’ a clinical appointment. Feedback received while workshopping the game highlights how games can facilitate unprecedented discussions across the table between receptionists, managers and clinicians. We conclude that in playing an actual game as a research output, members of primary care teams are able to see the ‘journey to a clinical appointment’ in a new light. Playing the game offers an activity that is paradoxically both enjoyable and unsettling in exposing how general practice reception processes advantage the most privileged individuals while disadvantaging individuals who experience broader social exclusion.

Abstract Background In Botswana, one fifth of the adult population is infected with HIV, with young women most at risk. Structural factors such as poverty, poor education, strong gender inequalities and gender violence render many young women unable to act on choices to protect themselves from HIV. A national trial is testing an intervention to assist young women to access government programs for returning to education, and improving livelihoods. Accessing marginalised young women (aged 16–29 and not in education, employment or training) through door-to-door recruitment has proved inefficient. We investigated social networks of young women to see if an approach based on an understanding of these networks could help with recruitment. Methods This mixed methods study used social network analysis to identify key young women in four communities (using in-degree centrality), and to describe the types of people that marginalised young women (n = 307) turn to for support (using descriptive statistics and then generalized linear mixed models to examine the support networks of sub-groups of participants). In discussion groups (n = 46 participants), the same young women helped explain results from the network analysis. We also tracked the recruitment method for each participant (door to door, peers, or key community informants). Results Although we were not able to identify characteristics of the most central young women in networks, we found that marginalised young women went most often to other women, usually in the same community, and with children, especially if they had children themselves. Rural women were better connected with each other than women in urban areas, though there were isolated young women in all communities. Peer recruitment contributed most in rural areas; door-to-door recruitment contributed most in urban areas. Conclusions Since marginalised young women seek support from others like themselves, outreach programs could use networks of women to identify and engage those who most need help from government structural support programs. Methods that rely on social networks alone may be insufficient, and so a combination of approaches, including, for instance, peers, door-to-door recruitment, and key community informants, should be explored as a strategy for reaching marginalised young women for supportive interventions.