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In Ukraine, women constitute a third of all new HIV infections, and injection drug use accounts for nearly half of HIV infections among women. Women who use drugs (WWUD) often have diminished access to drug use treatment, HIV care, and other health and social services or underutilize women-specific services such as maternal health services. While interpersonal and contextual factors diminish access to and utilization of services among WWUD, rules, processes, and bureaucratic structures also systematically exclude women from accessing services and resources. Institutions, bureaucratic processes, and instruments of legibility such as documents regulate who can and cannot access services and raise questions about "deservingness." In this paper, we use the lens of bureaucracy to explore paperwork as a form of structural violence through its production of "legible" citizens, often through reinforcement of gender stereotypes and moral narratives of deservingness. Between December 2017 and October 2018, we interviewed 41 medical and social service providers and 37 WWUD in two Ukrainian cities. Our analysis revealed that requirements for internal passports and residency permits—the primary state apparatus through which rights to services are granted in Ukraine—compelled participants to continually render themselves visible to the state in order to receive services, despite financial, logistical and other challenges that undermined women's ability to obtain documents. These requirements exposed them to new forms of stigma and exclusion, such as reduced opportunities for employment and losing custody of children. Nongovernmental organizations, due to funding cuts, curtailed direct services such as support groups but became liaisons between clients and the state. They enforced new narratives of deservingness, such as the ability to define "good" behavior or reward social relationships with agency staff. Ukraine's current reforms to social safety net institutions present an opportunity to interrogate underlying assumptions about spheres of responsibility for the country's most marginalized and stigmatized groups. • Access to services is essential to improve health outcomes for women who use drugs. • Bureaucratic structures systematically exclude some women from accessing services. • The bureaucratic process of document procurement is a form of structural violence. • NGOs impose new forms of moral scrutiny on vulnerable populations. [ABSTRACT FROM AUTHOR]

Since the depathologisation movement in 2007 to challenge the pathologisation of trans identities in Western psychiatry, significant developments have occurred, including revisions to Standards of Care and diagnostic criteria such as ICD-11's gender incongruence and DSM-5's gender dysphoria, acknowledging gender diversity as an expected part of human development. This paper argues that Japanese medical models reflect global issues but also have unique aspects shaped by cultural and linguistic nuances. Using critical discourse analysis, this paper examines how depathologisation discourses are perceived in the Japanese medical community, focusing on the term seidouitsusei-syōgai (gender identity disorder), presenting three ways in which seidouitsusei-syōgai is used: psychiatric disorder, syōgai / sikkan (impairment/disability/disorder), and diagnostic category. These uses are influenced by legal and social reforms, healthcare access and alignment with international classifications, while the medical profession's authority remains unexamined. Reflecting the structural challenges of diagnostic models in trans medicine, the interpretation of seidouitsusei-syōgai differs from the English phrase 'gender identity disorder' due to the specific connotations of syōgai in the Japanese context. By examining Japan's approach to depathologisation and medicalisation, this paper enriches the understanding of trans medicine and the impact of depathologisation discourse in Japan. • Japanese medical views on trans depathologisation through critical discourse analysis. • Focusing interpretations of seidouitsusei-syōgai(=gender identity disorder). • 3 usages, psychiatric, syōgai/sikkan and diagnostic, are influenced by social factors. • The authoritative role of the medical profession remains unexamined. • Japan sharing structural problems of diagnostic model but has specific connotations. [ABSTRACT FROM AUTHOR]

Virtual agents (VAs) and immersive virtual reality (VR) applications broaden the opportunities for accessing healthcare by transposing certain processes from the analogue world into a virtual realm. While these innovations offer a number of advantages including improved access for individuals in diverse geographic locations and novel therapeutic options, their implementation raises significant ethical, social, and legal implications. Key considerations pertain to the doctor-patient relationship, privacy and data protection, justice, fairness, and equal access as well as to issues of accountability, liability, and safety. This paper conducts a comprehensive review of the existing literature to analyse the ethical, social, and legal ramifications of employing VAs and VR applications in healthcare. It examines the recommended strategies to mitigate potential adverse effects and addresses current research gaps in this domain. • Virtual agents (VA) and immersive virtual reality (VR) are explored in the healthcare sector. • The paper investigates their ethical, legal, and social implications (ELSI) on basis of a literature review. • Key considerations pertain to the doctor-patient relationship, data protection, equal access, liability, and safety. • The paper gives an overview of the recommendations made to mitigate risks. [ABSTRACT FROM AUTHOR]

We demonstrate a transnationally situated dialogue as a method to bring ethnographic and historical research in Brazil, East Africa (Kenya, Tanzania and Uganda), India, Russia and Spain into conversation to show three cancer epistemics sites (research, detection, and care access) where the politics of cancer epistemics are at play. First, in the field of research, we show how certain ways of knowing, and certain questions about and interests in cancer, are privileged over others. Using examples from Spain and East Africa, we highlight how a shift towards microbiological and high-technology research has outpriced many more locally grounded research agendas, ignoring questions of industrial and capital accountability in cancer aetiology. Second, we look at ways of making cancer visible, how knowledge is mobilised in cancer detection and screening, where and for whom. We discuss the increased individualisation of risk which is reframing cancer surveillance and therapeutic agendas. Using examples from India, Spain and Brazil, we demonstrate how the epistemics of cancer detection generate discourses of blame and responsibility at the individual level and accentuate existing inequities whilst simultaneously absorbing patients and their families into complex networks of surveillance. Lastly, we examine how the epistemics of cancer implicate the very possibilities of accessing cancer care, shaping care pathways and possibilities for patients. With ethnographic examples from India, Russia and Brazil, we demonstrate how an orientation towards the individual shifts attention away from the commercialisation of healthcare and dominance of logics of profit in therapeutics. Throughout the paper, we point towards what is holding these cancer discourses together and grapple with how the politics of cancer epistemics are at play across the globe, even if they appear to be taking many different forms. Our approach highlights how practices are mirrored in the framing, implementation, detection and care of cancer with far-reaching effects. • A transnationally situated dialogue examines the global production of cancer knowledge. • Global research agendas side line industrial and capital driven carcinogenic links. • Individualisation of cancer detection obfuscates social and national inequities. • High-cost and technology driven interventions are privileged over local initiatives. • Patient perspectives on knowing and accessing cancer care are overlooked. [ABSTRACT FROM AUTHOR]

This paper examines rural-urban inequities in dusty lung (pneumoconiosis) deaths in China from 2002 to 2016 and possible causes for such inequities in the framework of social and spatial justice. The research reveals alarming results that have not been reported before. Dusty lung death rates for rural men increased twice as fast as those among urban men. The rural rates were particularly higher among middle-aged men, but lower in older age groups, as compared to urban rates. There were dramatic increases in death rates from 2011 to 2016 particularly among rural men aged 40–49 years old, who were many times more likely to die from dusty lung than urban men of a similar age. Chinese rural male victims also die at a younger age, compared to men in any of the seven countries or regions included in the study. For example, rural Chinese men aged 35–59 years old were many times more likely to die from dusty lung than their American, German, Polish, and Spanish counterparts. A possible explanation for the high death rates among middle-aged rural Chinese men is the tendency for rural migrant workers to be employed in unhealthy and unsafe working conditions in decent decades. Other explanations for the severe spatial injustice include the Hukou (household registration) system and the development policies that prioritize economic growth and urban development over occupational health and safety. The paper demonstrates the usefulness and weakness of the social and spatial justice concepts in understanding health inequity. Therefore, it proposes new definitions and models of social justice and spatial justice that combine the competing distribution and capabilities approaches and highlight interactions among multiple attributes. • Middle-aged rural men are worst victims of a growing dusty lung crisis in China. • They may be many times more likely to die from dusty lung than urban Chinese men. • Social and spatial injustice is responsible for such health inequity in China. • Urban growth-centered development policies are responsible for such injustice. • A new definition along with models of social justice and spatial justice are proposed. [ABSTRACT FROM AUTHOR]

Abstract With Universal Health Coverage (UHC) now entrenched among the top global development priorities, questions arise as to the conditions under which politicians commit to UHC and why certain strategies for health financing and access are favoured over others. The Ethiopian government has been piloting and scaling-up Community-Based Health Insurance (CBHI) for the informal sector since 2010 and is establishing Social Health Insurance for formal sector workers as a means of achieving UHC. CBHI covers 11 million people making it one of the largest health insurance schemes in Africa. This paper employs a process tracing methodology to examine the political drivers of the adoption and evolution of state health insurance based on 28 key informant interviews conducted between 2015 and 2018 with politicians, policymakers and donor officials. The paper highlights the inadequacy of existing theories—focusing on interest group mobilisation, electoral competition and bureaucratic actors—for explaining the Ethiopian case. Instead the paper proposes an 'Adapted Political Settlements' framework that explains the state's push to expand CBHI and stalled progress on SHI. This framework highlights the interests and ideas of the ruling coalition as important drivers of reform. In a context of ruling party dominance and minimal threat from electoral competition, the ruling coalition has sought to build political legitimacy through the delivery of socioeconomic progress, including health services. The policy idea of health insurance, meanwhile, has secured elite commitment due to its fit with deeply held ideas within the ruling coalition concerning the importance of self-reliance and resource mobilisation for development. Finally, the centralisation of power within the ruling coalition prior to 2012 enabled the emergence of a long-term developmental vision and the marginalisation of opposition to health insurance, while fragmentation of the ruling coalition since 2012 has led SHI to stall. Highlights • Ethiopia is pursuing Universal Health Coverage through health insurance. • Interest group, electoral and bureaucratic theories cannot explain the policy choices. • 'Adapted Political Settlements' framework explains CBHI expansion and SHI stalling. • Key factors include ruling coalition dominance and coherence, and party ideology. • The Ethiopian scheme was inspired by a study tour to Rwanda's Mutuelles de Santé. [ABSTRACT FROM AUTHOR]

Abstract That nutritional inequalities continue to proliferate at a global level requires new insight from all disciplines, given their formation at the intersection of broader inequities in food, health and other systems. This paper argues that critical social scientific perspectives are needed to supplement public health and food focused approaches, which, while helpful, tend to reduce research and intervention to remedial action on malnourished bodies or on food production. A number of alternative perspectives draw on work on both bodies and on systems which are reviewed here. Because both the causes and the impacts of poor nutrition are simultaneously embodied and systemic, our understanding is weakened without considering both sets of literature simultaneously. New-materialist, assemblage or posthuman approaches represent an evolution of these literatures which can reflect on dissolving socio-natural boundaries within contemporary (nutritional) science, whilst retaining a critical edge. Together, the various approaches within this paper help consider the conditions of everyday existence for those living with malnutrition and the range of bodily and systemic factors which assemble their condition. Highlights • Nutritional inequities are both systemic and bodied. • Systemic and bodily framings offer potential new understandings of nutrition. • Critical approaches pay attention to the framings of both systems and of bodies. • New materialist, assemblage and posthuman approaches emerge from such perspectives. • Malnutrition is the result of emergent and distributed socio-material relationships. [ABSTRACT FROM AUTHOR]

Abstract Small area health data are not always available on a consistent and robust routine basis across nations, necessitating the employment of small area estimation methods to generate local-scale data or the use of proxy measures. Geodemographic indicators are widely marketed as a potential proxy for many health indicators. This paper tests the extent to which the inclusion of geodemographic indicators in small area estimation methodology can enhance small area estimates of limiting long-term illness (LLTI). The paper contributes to international debates on small area estimation methodologies in health research and the relevance of geodemographic indicators to the identification of health care needs. We employ a multilevel methodology to estimate small area LLTI prevalence in England, Scotland and Wales. The estimates were created with a standard geographically-based model and with a cross-classified model of individuals nested separately in both spatial groupings and non-spatial geodemographic clusters. LLTI prevalence was estimated as a function of age, sex and deprivation. Estimates from the cross-classified model additionally incorporated residuals relating to the geodemographic classification. Both sets of estimates were compared against direct estimates from the 2011 Census. Geodemographic clusters remain relevant to understanding LLTI even after controlling for age, sex and deprivation. Incorporating a geodemographic indicator significantly improves concordance between the small area estimates and the Census. Small area estimates are however consistently below the equivalent Census measures, with the LLTI prevalence in urban areas characterised as 'blue collar' and 'struggling families' being markedly lower. We conclude that the inclusion of a geodemographic indicator in small area estimation can improve estimate quality and enhance understanding of health inequalities. We recommend the inclusion of geodemographic indicators in public releases of survey data to facilitate better small area estimation but caution against assumptions that geodemographic indicators can, on their own, provide a proxy measure of health status. Highlights • A novel cross-classified extension to small area estimation methodology. • Small area estimation of health indicators can be enhanced by geodemographic data. • Geodemographics and deprivation independently impact small area health estimates. • Deprived urban communities have much worse health than expected. [ABSTRACT FROM AUTHOR]

Early cervical cancer screening has been shown to be beneficial in reducing cervical cancer related deaths. Despite the benefits of early cervical cancer screening, uptake remains limited, with wide disparities in access and uptake in most developing countries. As part of a larger study, this paper uses a socio-ecological framework to explain the determinants of cervical cancer knowledge and screening among women of reproductive age (15–49 years) in Kenya. We conducted a multilevel analysis of cervical cancer knowledge (n = 11,138) and screening (n = 10,333) using the 2014 Kenya Demographic and Health Survey (KDHS). Results show regional disparities in cancer knowledge and the utilization of cervical cancer screening services; regions with high wealth inequality (OR = 0.70, 95% CI [0.56–0.87]) emerged as vulnerable regions where women were less likely to screen for cervical cancer. Gender equity, health insurance coverage and education level significantly predicted cervical cancer screening rates. Results further revealed regional as well as rural-urban wealth inequalities in cervical cancer screening. We argue that given that Kenyan women are highly exposed to human papilloma virus (HPV) due to the legacy of human immunodeficiency virus (HIV) in the country, cervical cancer may be the next epidemic if integrated measures are not adopted to increase cervical cancer knowledge and overcome the barriers to utilizing early screening services. The paper concludes with policy recommendations and directions for future research. [ABSTRACT FROM AUTHOR]

According to popular understandings, children grow from a state of dependence to eventually become independent adults. Interdependence helps to disrupt the in/dependence binary and is a useful concept for making sense of the experiences young people with variations in sex characteristics in relation to healthcare. This study used semi-structured interviews with 32 health professionals, 33 caregivers and 12 young people recruited in the UK and Sweden. The analysis is guided by the questions: (1) how do young people, carers and health professionals position themselves in the adult/young person relationship in the context of healthcare? (2) how is the (in/ter)dependence of young people imagined when young people, carers and health professionals talk about healthcare? Our analysis shows how carers and health professionals might support dominant understandings about young people growing towards independence while providing little opportunity for young people's agency and voice. Interviews with young people gave clear examples of their negotiating relational ways of being, seeking agency in the context of healthcare and not simply becoming independent of adults. This analysis also draws attention to the ways young people might be silenced within healthcare contexts. The present paper is based on secondary analysis of data from the SENS. It works with concepts of relationality and interdependence to draw out the possibilities of voice and agency for young people with variations in sex characteristics in healthcare contexts. • Youth with variations in sex characteristics are sometimes silenced in the clinic. • There is sometimes too little room for youth agency in healthcare. • A relational approach could improve the healthcare experiences of young people. • Working towards interdependence, not simply independence, can support youth. • It is important to value knowledge that is based on intersex lived experience. [ABSTRACT FROM AUTHOR]

The United States offers two markedly different subsidy structures for private health insurance. When covered through employer-based plans, employees and their dependents benefit from the exclusion from taxable income of the premiums. Individuals without access to employer coverage may obtain subsidies for Marketplace coverage. This paper seeks to understand how the public subsidies embedded in the privately financed portion of the U.S. healthcare system impact the payments families are required to make under both ESI and Marketplace coverage, and the implications for finance equity. Using the Household Component of the Medical Expenditure Panel Survey (MEPS-HC) and Marketplace premium data, we assess horizontal and vertical equity by calculating public subsidies for and expected family spending under each coverage source and using Lorenz curves and Gini and concentration coefficients. Our study pooled the 2018 and 2019 MEPS-HC to achieve a sample size of 10,593 observations. Our simulations showed a marked horizontal inequity for lower-income families with access to employer coverage who cannot obtain Marketplace subsidies. Relative to both the financing of employer coverage and earlier Marketplace tax credits, the more generous Marketplace premium subsidies, first made available in 2021 under the American Rescue Plan Act, substantially increased the vertical equity of Marketplace financing. While Marketplace subsidies have clearly improved equity within the United States, we conclude with a comparison to other OECD countries highlighting the persistence of inequities in the U.S. stemming from its noteworthy reliance on employer-based private health insurance. • United States uses employer and individual private health insurance coverage. • No recent investigations of horizontal and vertical equity of U.S. private coverage. • Analysis of Gini coefficients and Lorenz curves suggests regressivity. • Public policies including insurance subsidies can reduce inequities. [ABSTRACT FROM AUTHOR]

The present paper aims to contribute to the debate about the temporal relationships between place and health. It explores the notion of ‘daycourse of place’ echoing the discussion which recently occurred in this journal about the ‘lifecourse of place’ (Andrews, 2017; Lekkas et al., 2017a, b). When highlighting the importance of time in shaping health within places, most of studies focus either on the trajectories of places over a matter of years or the daily trajectories of people in link with their activity space. However, daily trajectories of places remain a poor cousin in place and health literature. This paper is intended to overcome ‘jetlag’, which places suffer when they are labelled with frozen attributes over a 24-h period. It explores the values and feasibility of exploring daily trajectories of places to investigate place effects on health or to design area-based interventions for public health action. More than just a metaphor, the ‘daycourse of place’ appears to be an inspiring framework to elaborate the importance of daily temporal relationalities for research and action in place-based health inequalities. [ABSTRACT FROM AUTHOR]

This paper examines the organisational dynamics that arise in health promotion aimed at reducing health inequalities. The paper draws on ethnographic fieldwork among public health officers in Danish municipalities and qualitative interviews from an evaluation of health promotion programmes targeting homeless and other marginalised citizens. Analytically, we focus on ‘boundary work’, i.e. the ways in which social and symbolic boundaries are established, maintained, transgressed and negotiated, both at the administrative level and among frontline professionals. The paper discusses three types of boundary work: (i) demarcating professional domains; (ii) setting the boundaries of the task itself; and (iii) managing administrative boundaries. The main argument is that the production, maintenance and transgression of these three types of boundaries constitute central and time-consuming aspects of the practices of public health professionals, and that boundary work constitutes an important element in professional practices seeking to ‘tame a wicked problem’, such as social inequalities in health. A cross-cutting feature of the three types of boundary work is the management of the divide between health and social issues, which the professionals seemingly seek to uphold and transgress at the same time. The paper thus contributes to ongoing discussions of intersectoral action to address health inequalities. Furthermore, it extends the scope and application of the concept of boundary work in the sociology of public health by suggesting that the focus in previous research on professional demarcation be broadened in order to capture other types of boundaries that shape, and are shaped by, professional practices. [ABSTRACT FROM AUTHOR]

It is hard to ignore the importance of patient time investment in the production of health since the influential paper by Grossman (1972). Patients' time includes time to admission, travel time, waiting time, and treatment time and can be substantial. Patients' time is, however, often ignored in economic analyses. This may lead to biased results and inappropriate policy recommendations, which may eventually influence patients' health, wellbeing and welfare. How to value patient time is not straightforward. Although there is some emerging literature on the monetary valuation of patient time, an important challenge remains to develop an approach that can be used to monetarily value time of patients not participating in the labour market. We aim to contribute to the health economics literature by describing and empirically illustrating how to monetarily value the time of patients not participating in the labour market comprehensively, using the contingent valuation method. It is worth noting that our method can also be applied to people participating in the labour market. This paper describes the development of the contingent valuation survey. We apply our survey approach to a sample of 238 Dutch patients not participating in the labour market: n = 107 Radiotherapy department (data collected between November 2011 and January 2013); n = 44 Rehabilitation department (March 2012–May 2012); n = 87 Orthopaedics department (January to June 2013). Results show that those patients value waiting time the highest (€30.10 per hour) and value travel and treatment time equally with respectively €13.20 and €13.32 per hour. This paper encourages future empirical research refining and applying the developed survey methodology to create more data on how other subgroups of individuals value their patients' time. [ABSTRACT FROM AUTHOR]

Objective To identify elements of endorsed definitions of equity in healthcare and classify domains of these definitions so that policy makers, managers, clinicians, and politicians can form an operational definition of equity that reflects the values and preferences of the society they serve. Design Systematic review where verbatim text describing explicit and implicit definitions of equity were extracted and subjected to a thematic analysis. Data sources The full holdings of the AMED, CINAHL plus, OVID Medline, Scopus, PsychInfo and ProQuest (ProQuest Health & Medical Complete, ProQuest Nursing and Allied Health Source, ProQuest Social Science Journals) were individually searched in April 2015. Eligibility criteria for selecting studies Studies were included if they provided an original, explicit or implicit definition of equity in regards to healthcare resource allocation decision making. Papers that only cited earlier definitions of equity and provided no new information or extensions to this definition were excluded. Results The search strategy yielded 74 papers appropriate for this review; 60 of these provided an explicit definition of equity, with a further 14 papers discussing implicit elements of equity that the authors endorsed in regards to healthcare resource allocation decision making. Five key themes emerged i) Equalisation across the health service supply/access/outcome chain, ii) Need or potential to benefit, iii) Groupings of equalisation, iv) Caveats to equalisation, and v) Close enough is good enough. Conclusions There is great inconsistency in definitions of equity endorsed by different authors. Operational definitions of equity need to be more explicit in addressing these five thematic areas before they can be directly applied to healthcare resource allocation decisions. [ABSTRACT FROM AUTHOR]

How do we make a difference? This paper traces the connections made between quantified knowledge, population health, and social justice by examining the efforts of population scientists to assess sexuality as a point of difference within population-based data systems, including on national health and social surveys, electronic medical records, and the Census. Population scientists emphasize the importance of measuring social difference in order to identify and remedy structural disadvantage. This evaluation requires the assessment of difference and the comparison of distinct groups across standardized outcome measures. In quantifying social difference, however, population scientists obscure or minimize several difficulties in creating comparable populations. I explore some of these challenges by highlighting three central tensions: the separation of difference from other aspects and categories of social experience, the reduction of difference through the use of one over several possible measures, and the enactment of difference as quantified knowledge loops back into society. As a theoretical inquiry into the form of social difference as it is conceptualized, operationalized, and materialized across the science-society nexus, this paper identifies the various commitments made during processes of scientific evaluation. By attending to the values and priorities that exist within and through practices of quantification, I aim to address the problem of measuring social difference as it pertains to the issues of social justice and health equity. [ABSTRACT FROM AUTHOR]

To access contemporary healthcare, patients must find and navigate a complex socio-technical network of human and digital actors linked in multi-modal pathways. Asynchronous, digitally-mediated triage decisions have largely replaced synchronous conversations between humans. In this paper, we draw on a large qualitative dataset from a multi-site study of remote and digital technologies in general practice to understand widening inequities of access. We theorise our data by bringing together traditional candidacy theory (in particular, concepts of self-assessment, help-seeking, adjudication and negotiation) and socio-technical and technology structuration theories (in particular, concepts of user configuration, articulation, distanciation, disembedding, and recursivity), thus producing a novel theory of digital candidacy. We propose that both human and technological actors (in different ways) embody social structures which affect how they 'act' in social situations. Digital technologies contain inbuilt assumptions about users' capabilities, needs, rights, and skills. Patients' ability to self-assess as sick, access digital platforms, self-advocate, and navigate multiple stages in the pathway, including adapting to and compensating for limitations in the technology, vary widely and are markedly patterned by disadvantage. Not every patient can craft an accurate digital facsimile on which the subsequent adjudication decision will be made; those who create incomplete, flawed or unpersuasive digital facsimiles may be deprioritised or misdirected. Staff who know about such patients may use articulation measures to ensure a personalised and appropriate access package, but they cannot identify or fully mitigate all such cases. The decisions and actions of human and technological agents at the time of an attempt to access care can significantly influence, disrupt, and reconstitute candidacy both immediately and recursively over time, and also recursively shape the system itself. These findings underscore the need for services to be (co-)designed with attention to the exclusionary tendencies of digital technologies and technology-supported processes and pathways. • Digital access and triage involves a network of technological and human agents. • Digitalised systems exacerbate existing inequities, and create new ones. • Technologies are encoded with assumptions, limiting their use and accessibility. • These assumptions lock out some users, recursively affecting health service usage. • Individual practices' digital options must depend on local staff and patient needs. [ABSTRACT FROM AUTHOR]

English-language reporting on the continuing difficulties in accessing Evusheld reflects the marginalization of immunocompromised people in discussions about the public policy response to Covid-19. Moreover, the lack of available data on global Evusheld access, particularly in low-income countries, has emerged as a key form of nonknowledge that must be redressed within public health research. Through examining how knowledge about domestic and global barriers to Evusheld access circulates, and does not circulate, within The New York Times , this paper identifies a case study of the social production of ignorance related to a key issue in the Covid-19 pandemic. Drawing on science and technology studies, the history of science and media studies, I situate these trends in the context of longer explanatory histories of nonknowledge. First, through a critical discourse analysis of the New York Times' reporting on Evusheld access in the U.S., I trace the individualizing framework evident in many articles to longstanding trends in reporting on health and illness, and to the structural marginalization of immunocompromised people in U.S. Secondly, I argue that the near-total absence of reporting on Evusheld access in low-income countries is consistent with the longstanding structural neglect of health crises in the global south. • New York Times coverage of preventative treatment Evusheld rarely discusses access barriers. • Access barriers discussed are largely logistical rather than structural. • The perspectives of immunocompromised people are rarely included in Times articles on Evusheld. • Failure to include voices from impacted communities contributes to agnogenesis. • Centering the perspectives of constituencies most impacted by a health crisis will advance health equity. [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]

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]

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]

For Chinese policymakers, shouldering responsibility is often associated with high liability risk, thus resulting in low-level care for risky and stigmatized populations such as drug users. Therefore, it is crucial to explore ways to improve care access in such an uneasy policy environment. Based on long-term ethnographic fieldwork conducted in Yunnan province in southwestern China from 2013 to 2021, this paper traces the policy-making process of the Yunnan Province Methadone Oral Solution Take-Home Treatment Work Proposal. All stakeholders involved considered this policy attempt "impossible" at first, as the highly addictive methadone becomes an illegal drug once it is taken outside a clinical setting. By analyzing how a group of local government officials, together with medical practitioners and drug users, strive to legitimize and ultimately implement the policy, I argue that people's concern over liability risks strengthens the boundary between methadone as a "drug" and methadone as a "medicine," between methadone solution drinkers as "drug users" and as "patients," and between "inside the clinic" and "outside the clinic." By utilizing a culturalist approach to explore the possibility of care in such a context, this paper reveals that a " heqing heli hefa worthy-of-being-cared-for" discourse is crucial in that it acts as symbolic capital to dissolve the above boundaries embedded in the dominant political culture. Moreover, it is the key cultural logic of the "building" of care. The findings also illustrate how local policymakers negotiate and balance responsibility and liability to create a potential policy space for enabling care practices. Additionally, this study sheds light on the inclusion of care for the most stigmatized and marginalized populations, and has broad implications for policy-making in other contexts. • In the field of drug control, policies often delay and even exclude care for drug users. • Concerns over liability risks hamper users' access to take-home methadone service. • Liability risks affect people's categorizing of methadone as a medicine or a drug. • Privatization of compassion helps to mitigate liability risks. • Policymaking could also be a process of accumulating and building care. [ABSTRACT FROM AUTHOR]

Despite impressive global investment in reproductive health programs in West Africa, maternal mortality remains unacceptably high and obstetric care is often inadequate. Fertility is among the highest in the world, while contraceptive prevalence remains among the lowest. This paper explores the social and technical dimensions of this situation. We argue that effective reproductive health programs require analyzing the interfaces between technical programs and the social logics and behaviors of health professionals and client populations. Significant gaps between health programs’ goals and the behaviors of patients and health care professionals have been observed. While public health projects aim to manage reproduction, sexuality, fertility, and professional practices are regulated socially. Such projects may target technical practices, but access to care is greatly influenced by social norms and ethics. This paper shows how an empirical anthropology that investigates the social and technical interfaces of reproduction can contribute to improved global health. [ABSTRACT FROM AUTHOR]

South Africa's legal framework on sexual and reproductive health (SRH) care for teenagers is complex. On the one hand, the law protects their right to make decisions regarding reproduction e e.g. giving girls of any age the right to terminate a pregnancy, and allowing adolescents to consent to receive contraception from age 12. On the other hand, the Sexual Offences Act sets the age of consent to sex at 16 years, and requires mandatory reporting of anyone younger. These contradictory obligations mean that nurses, doctors and counsellors are expected to provide care, and counsel teenagers about their choices, but also report and enforce the law. They must therefore make judgments about inherently moral issues: should teenagers be having sex, and what services should they receive? Based on in-depth interviews at 28 healthcare facilities conducted in 2012, and data from workshops on the 'conflicting laws' held in 2014, the paper uses the theoretical framework of street-level bureaucracy to understand barriers to nurses providing SRH care for teenagers in South Africa, and the implication that this has for adolescents' SRH. The paper argues that nurses' adaptation of the law is a response to significant structural constraints, moral discomfort, and poor understanding of the law e all taken against an ethical framework that emphasizes quality, responsive patient care. The result is uneven implementation that undermines SRH information, access to services, and ultimately increases risks for teens. [ABSTRACT FROM AUTHOR]

Rapid increase in the scale, speed and spread of immigration over the past two decades has led to an increase in complexity of populations termed superdiversity. Concerns have been expressed about impacts of the pressure that superdiversity is said to place upon maternity services. High migrant fertility and infant and maternal mortality rates have long been observed in diverse areas with inadequate antenatal monitoring seen as a major causal factor in migrants' maternity outcomes. Using qualitative data from a study of new migrants' access to maternity services in the UK's West Midlands region, with some of the highest infant and maternal mortality rates in Europe, this paper looks at the reasons migrants' access to antenatal care is poor. The paper finds that contrary to earlier studies which pointed to a lack of priority placed on such care by migrants, a combination of structural, legal and institutional barriers prevent migrant women accessing effective antenatal care. [ABSTRACT FROM AUTHOR]

This paper utilizes eighteen months of ethnographic and interview research undertaken in 2003 and 2004 as well as follow-up fieldwork from 2005 to 2007 to explore the sociocultural factors affecting the interactions and barriers between U.S. biomedical professionals and their unauthorized Mexican migrant patients. The participants include unauthorized indigenous Triqui migrants along a transnational circuit from the mountains of Oaxaca, Mexico, to central California, to northwest Washington State and the physicians and nurses staffing the clinics serving Triqui people in these locations. The data show that social and economic structures in health care and subtle cultural factors in biomedicine keep medical professionals from seeing the social determinants of suffering of their unauthorized migrant patients. These barriers lead clinicians inadvertently to blame their patients--specifically their biology or behavior--for their suffering. This paper challenges the focus of mainstream cultural competency training by showing that it is not the culture of the patient, but rather the structure and culture of biomedicine that form the primary barriers to effective multicultural health care.

Routine childhood immunizations against measles and DPT are part of the World Health Organization's (WHO) Expanded Program on Immunization (EPI) set up in 1974, with the aim of reducing childhood morbidity and mortality. Despite this, immunization rates are sub-optimal in developing countries such as India, with wide heterogeneity observed across districts and socio-economic characteristics. The aim of this paper is to examine district-level variations in the propensity to vaccinate a child in India for measles and DPT3, and analyse the extent to which these immunizations are given age-inappropriately, either prematurely or delayed. The present study uses data from the Indian District Level Household Survey (DLHS-3) collected in 2008, and the final sample contains detailed information on 42157 children aged between 12 and 60 months, across 549 Indian districts for whom we have complete information on immunization history. Our empirical study analyses: (i) the district-level average immunization rates for measles and DPT3, and (ii) the extent to which these immunizations have been given age-appropriately. A key contribution of this paper is that we link the household-level data at the district level to data on availability and proximity to health infrastructure and district-level socio-economic factors. Our results show that after controlling for an array of socio-economic characteristics, across all our models, the district's income per capita is a strong predictor of better immunization outcomes for children. Mother's education level at the district-level has a statistically significant and positive influence on immunization outcomes across all our models. [ABSTRACT FROM AUTHOR]

The African communications ‘revolution’ has generated optimism that mobile phones might help overcome infrastructural barriers to healthcare provision in resource-poor contexts. However, while formal m-health programmes remain limited in coverage and scope, young people are using mobile phones creatively and strategically in an attempt to secure effective healthcare. Drawing on qualitative and quantitative data collected in 2012–2014 from over 4500 young people (aged 8–25 y) in Ghana, Malawi and South Africa, this paper documents these practices and the new therapeutic opportunities they create, alongside the constraints, contingencies and risks. We argue that young people are endeavouring to lay claim to a digitally-mediated form of therapeutic citizenship, but that a lack of appropriate resources, social networks and skills (‘digital capital’), combined with ongoing shortcomings in healthcare delivery, can compromise their ability to do this effectively. The paper concludes by offering tentative suggestions for remedying this situation. [ABSTRACT FROM AUTHOR]

The paper analyzes the healthcare-seeking behavior of South Korean immigrants in Toronto, Canada, and how transnationalism shapes post-migration health and health-management strategies. Built upon largely separate research areas in ethnicity and health, health geography, and transnationalism, the paper conceptualizes immigrant health as influenced by individual characteristics, the migration and resettlement experience, and place effects at both a local and a transnational scale. A mixed-method approach is used to capture insights into health status and experiences in accessing local and transnational healthcare among South Korean immigrants – a fast growing visible minority group in Canada. Statistical analysis of data from the Canadian Community Health Survey discloses patterns and trends in health and healthcare use among the Korean Canadian, overall foreign-born, and native-born populations. Focus groups reveal in-depth information on the decline of Korean immigrants' health status and the array of sociocultural, economic and geographic barriers in accessing healthcare in Canada, which gave rise to their transnational use of health resources in the home country. The transnational strategies included traveling to South Korea for medical examinations or treatment, importing medications from South Korea to Canada, and consulting health resources in South Korea by phone or email. The results provide timely knowledge on how a recent immigrant group adapts to Canada in the domain of health and adds a transnational perspective to the literature on ethnicity and health. [ABSTRACT FROM AUTHOR]

As rates with which women are incarcerated have risen around the world, research examining how incarceration affects the health of people who are pregnant, their newborns, and their family members has burgeoned. Lived experience is seldom accounted for in this research, however, highlighting a gap with relevance to advocates, policy makers, researchers, and practitioners seeking to better understand health inequities and redress human suffering. In this paper we present a qualitative meta-synthesis of 31 papers reporting qualitative studies of how people who are incarcerated in prisons and jails around the world experience pregnancy, labour and childbirth, and the postpartum period. Theoretical perspectives from the reproductive justice and prison abolition movements guided our analysis, which identified connectedness (to baby) and disconnectedness (from support) as twinned themes characterizing the lived experiences of navigating pregnancy in a carceral institution. We argue that the conditions of reproductive justice – including self-determination in pregnancy, in parenting, and in managing one's reproductive capacity – are fundamentally irreconcilable with mass incarceration. We conclude by considering the strategic opportunities for health practitioners and researchers to support the movement for prison abolition by mobilizing health-focused arguments for decarceration. • Pregnant people who are incarcerated face barriers to accessing healthcare and social supports. • Common carceral and clinical practices during labour are retraumatizing. • Postpartum opportunities for connection with newborns are contingent and uncertain. • People with lived experience should direct carceral research and research agendas. [ABSTRACT FROM AUTHOR]

For several decades, control programmes for human African trypanosomiasis (HAT, or sleeping sickness) in South Sudan have been delivered almost entirely as humanitarian interventions: large, well-organised, externally-funded but short-term programmes with a strategic focus on active screening. When attempts to hand over these programmes to local partners fail, resident populations must actively seek and negotiate access to tests at hospitals via passive screening. However, little is known about the social impact of such humanitarian interventions or the consequences of withdrawal on access to and utilisation of remaining services by local populations. Based on qualitative and quantitative fieldwork in Nimule, South Sudan (2008–2010), where passive screening necessarily became the predominant strategy, this paper investigates the reasons why, among two ethnic groups (Madi returnees and Dinka displaced populations), service uptake was so much higher among the latter. HAT tests were the only form of clinical care for which displaced Dinka populations could self-refer; access to all other services was negotiated through indigenous area workers. Because of the long history of conflict, these encounters were often morally and politically fraught. An open-door policy to screening supported Dinka people to ‘try’ HAT tests in the normal course of treatment-seeking, thereby empowering them to use HAT services more actively. This paper argues that in a context like South Sudan, where HAT control increasingly depends upon patient-led approaches to case-detection, it is imperative to understand the cultural values and political histories associated with the practice of testing and how medical humanitarian programmes shape this landscape of care, even after they have been scaled down. [ABSTRACT FROM AUTHOR]

Abstract: Transgender and gender nonconforming people face stigma and discrimination from a wide variety of sources and through numerous social realms. Stigma and discrimination originating from biomedicine and health care provision may impact this group's access to primary care. Such stigma and discrimination may originate not only from direct events and past negative experiences, but also through medicine's role in providing treatments of transitioning, the development of formal diagnoses to provide access to such treatments, and the medical language used to describe this diverse group. This paper examines the postponement of primary curative care among this marginalized group of people by drawing from the National Transgender Discrimination Survey, one of the largest available datasets for this underserved group. This paper also proposes an innovate categorization system to account for differences in self-conceptualization and identity, which has been of considerable concern for transgender and gender nonconforming communities but remains underexplored in social and health research. Results suggest that experience, identity, state of transition, and disclosure of transgender or gender nonconforming status are associated with postponement due to discrimination. Other findings suggest that postponement associated with primary place of seeking care and health insurance has ties to both discrimination and affordability. These findings highlight the importance of combating stigma and discrimination generated from within or experienced at sites of biomedicine or health care provision in improving access to care for this group of people. Improving access to care for all gender variant people requires a critical evaluation of existing research practices and health care provision to ensure that care is tailored as needed to each person's perspective in relation to larger social processes. [Copyright &y& Elsevier]

Abstract: Internationally, there is extensive empirical evidence that a strong primary care-led health system is associated with improved health outcomes, increased quality of care, decreased health inequalities and lower overall health-care costs. Within primary care, factors influencing access to, and utilisation of, general practitioner (GP) services have been widely examined and this paper focuses on the role of user financial incentives. In particular, user charges for health care have been observed to deter health-care utilisation. Relative to other countries, the Irish health-care system is unusual in that the majority of the population are required to pay out-of-pocket for GP care. However, in 2005 the Irish government extended eligibility for free GP care to a further small subset of the population. Using micro-data from a nationally representative survey of the population in 2007, this paper analyses the impact of differential coverage of free GP services on GP utilisation in Ireland. Results from multivariate regression analysis indicate that GP utilisation is significantly more likely in the context of free GP care, controlling for a range of demographic, socio-economic and health factors. Interpretation of the results for the new category of coverage is complicated by possible pent-up demand and selection effects. [Copyright &y& Elsevier]

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]

The aspiration of liveable cities, underpinned by the New Urban Agenda, is gaining popularity as a mechanism to enhance population health and wellbeing. However, less attention has been given to understanding how urban liveability may provide an opportunity to redress health inequities. Using an environmental justice lens, this paper investigates whether urban liveability poses an opportunity or threat to reducing health inequities and outlines a future research agenda. Selected urban liveability attributes, being: education; employment; food, alcohol, and tobacco; green space; housing; transport; and walkability, were investigated to understand how they can serve to widen or narrow inequities. Some domains showed consistent evidence, others suggested context-specific associations that made it difficult to draw general conclusions, and some showed a reverse patterning with the social gradient, but with poorer outcomes. This suggests urban liveability attributes have equigenic potential, but operate within a complex system. We conclude more disadvantaged neighbourhoods and their residents likely have additional policy and design considerations for optimising outcomes, especially as changes to the contextual environment may impact neighbourhood composition through displacement and/or pulling up effects. Future research needs to continue to explore downstream associations using longitudinal and natural experiments, and also seek to gain a deeper understanding of the urban liveability system, including interactions, feedback loops, and non-linear and linear responses. There is a need to monitor neighbourhood population changes over time to understand how liveability impacts the most vulnerable. Other areas worthy of further investigation include applying a life course approach and understanding liveability within the context of other adversities and contextual settings. • It is unclear how the urban liveability agenda could redress health inequities. • Urban liveability has equigenic potential, but operates in a complex system. • Contextual changes may impact composition by displacement or pulling up effects. • Need to monitor neighbourhoods to understand liveability impacts for the vulnerable. • Future research includes investigating other adverse and contextual settings. [ABSTRACT FROM AUTHOR]

Research into the role of place in shaping inequalities in health has focused largely on examining individual and/or localised drivers, often using a context-composition framing. Whilst this body of work has advanced considerably our understanding of the effects of local environments on health, and re-established an awareness of the importance of place for health, it has done so at the expense of marginalising and minimising the influences of macro political and economic structures on both place and health. In this paper, we argue that: (i) we need to scale up our analysis, moving beyond merely analysing local horizontal drivers to take wider, vertical structural factors into account; and (ii) if we are serious about reducing place-based health inequalities, such analysis needs be overtly linked to appropriate policy levers. Drawing on three case studies (the US mortality disadvantage, Scotland's excess mortality, and regional health divides in England and Germany) we outline the theoretical and empirical value of taking a more political economy approach to understanding geographical inequalities in health. We conclude by outlining the implications for future research and for efforts to influence policy from 'scaling up' geographical research into health inequalities. • Health-place research commonly examines focuses individual and/or localised drivers. • Health geography should 'scale up' analysis of health-place relationships. • Research needs to account for wider, vertical and structural factors. • Political economic approaches add value to insight on geographic health inequalities. • Considers the policy implications of taking a political economy approach. [ABSTRACT FROM AUTHOR]

Indicators of deprivation based on income and education might offer a blunt tool for inequality analysis in universal health systems with free access to care and thereby preventing the identification of groups experiencing the largest inequality. Also, analysis methods based on ranking the population by income or education, such as concentration curves and indices, are unsuitable for evaluating the impact of a health programme on inequality. This paper uses a new method for inequality analysis based on the Health Care Deprivation profiles' approach, allowing for: (1) considering multi-dimensional aspects of deprivation in the inequality analysis, (2) a graphical representation of the distribution of inequality, and (3) a range of additive decomposable inequality indices consistent with dominance. We apply this method and a Difference in Differences approach to evaluate the impact of a disease management programme aiming at reducing underutilisation of GP services for diabetic patients in Denmark. The programme introduced a set of non-pecuniary incentives empowering GPs with feedback reports on their performance and comparisons with other peers. Our study population includes 93,849 diabetic patients aged 18 + registered in 563 GP practices in Denmark; a total of 246 of these practices joined the programme, and 317 are used as control. The results show that patients experiencing the largest inequality in the top quintile of the distribution are characterised by deprivation in multiple socio-economic and morbidity dimensions that are not captured fully by income and education. The programme significantly reduced inequality in access to pivotal services, such as blood tests and preventive visits, for all patients and, with greater magnitude, for the most-deprived patients. Non-pecuniary incentives may be an effective tool for GPs to improve access to care in the most vulnerable patients. • Inequality in access may be underestimated when based on income and education only. • A new inequality approach evaluating the impact of a disease management programme. • The programme reduced inequality in patients with the largest shortfall in use of care. • These patients are not fully captured by their deprivation in terms of income and education. [ABSTRACT FROM AUTHOR]

Abstract Sex work-related stigma is prevalent in urban India. While HIV-stigma is often discussed in urban Indian health contexts, rarely is sex work-related stigma investigated as it shapes sex workers' health experiences. This paper discusses the findings of an ethnographic study with women who practice sex work (WPSW), healthcare providers, and NGO workers in Delhi, India over seven months in 2017. We apply a tri-tiered model of stigma as constituted of experiential, symbolic, and structural forms, to better understand how WPSW experience sex work-related stigma as it relates to their health. Identifying and understanding manifestations and experiences of stigma is crucial to supporting WPSW health. We conclude that in the face of criminalized legal contexts, both non-governmental and governmental interventions to improve WPSW's health must contend with their own tendencies to reinforce prevailing stereotypes and symbols that stigmatize sex work and the people who engage in it. Highlights • Sex work stigma shapes and constrains public health efforts directed at sex workers. • Sex work stigma is only one layer of the many stigmas experienced by sex workers. • Public health efforts to support sex workers must go beyond HIV. [ABSTRACT FROM AUTHOR]

Abstract The paper develops and illustrates a new multivariate approach to analysing inequity in health care. We measure multiple inequity in health care relating to multiple equity-relevant variables – including income, gender, ethnicity, rurality, insurance status and others – and decompose the contribution of each variable to multiple inequity. Our approach encompasses the standard bivariate approach as a special case in which there is only one equity-relevant variable, such as income. We illustrate through an application to physician visits in Brazil, using data from the Health and Health Care Supplement of the Brazilian National Household Sample Survey, comprising 391,868 individuals in the year 2008. We find that health insurance coverage and urban location both contribute more to multiple inequity than income. We hope this approach will help researchers and analysts shed light on the comparative size and importance of the many different inequities in health care of interest to decision makers, rather than focus narrowly on income-related inequity. Highlights • We developed methods for measuring multiple inequity in health care. • Multiple inequity relates to multiple equity-relevant variables, not just income. • We analysed multiple inequity in physician visits in Brazil using survey data. • Insurance coverage and geography contributed more to multiple inequity than income. [ABSTRACT FROM AUTHOR]

Abstract Geographical deprivation indices such as the English Index of Multiple Deprivation (IMD) have been widely used in healthcare research and planning since the mid-1980s. However, such indices normally provide a measure of disadvantage for the whole population and can be inflexible to adaptation for specific geographies or purposes. This can be an issue, as the measurement of deprivation is subjective and situationally relative, and the type of deprivation experienced within rural areas may differ from that experienced by urban residents. The objective of this study was to develop a Rural Deprivation Index (RDI) using the English county of Norfolk as a case study, but with a view to adopting a flexible approach that could be used elsewhere. It is argued that the model developed in this research gives clarity to the process of populating an index and weighting it for a specific purpose such as rural deprivation. This is achieved by 'bundling' highly correlated indicators that are applicable to both urban and rural deprivation into one domain, and creating a separate domain for indicators relevant to the setting of interest, in this case rural areas. A further domain is proposed to account for population differences in rural areas. Finally, a method was developed to measure variability in deprivation within small areas. The RDI results in more rural areas in Norfolk falling in the most deprived quintile, particularly those classified as 'Rural town and fringe in sparse settings'; these areas also have high levels of heterogeneity of deprivation when using the variability measure created. This model proposed has the potential to provide a starting point for those who wish to create a summary deprivation measure taking into account rurality, or other local geographic factors, and as part of a range of approaches that can be used to allocate, or apply for, resources. Highlights • National indices of deprivation typically poorly represent rural disadvantage. • Paper presents new method to better depict deprivation in rural settings. • Depicts granularity of rural disadvantage better than English deprivation index. • Resulting index valuable for rural health and social service planning. [ABSTRACT FROM AUTHOR]

Abstract The Brazilian Unified Health System was created in the late 1980s to ensure free universal access to health care and was funded by taxes and social contributions. The persistent inequity in access to health services in favour of richer individuals in Brazil has been observed in the literature. However, to the best of our knowledge, no measurement of inequality in medicine use or private health insurance (PHI) among children has been performed with longitudinal data. This paper uses inequality indices and their decompositions to analyse the income-related inequalities/inequities in children's health care in the city of Pelotas, Brazil, using longitudinal data following children from 12 to 72 months of age. Our sample with data in all waves has between 1877 and 2638 children (varying according to outcome). We seek to answer three questions: i) How does the inequality/inequity in health care evolve as children grow up? ii) What are the main factors associated with inequality in children's health care? iii) How much of the change in inequality/inequity is explained by mobility in children's health care and income mobility? We found that inequities in health care have their beginnings in early childhood but that there was a reduction in inequity at 72 months of age. Ownership of children's PHI was associated with greater pro-rich inequity in health care. The reduction in inequality/inequity was linked to mobility in the sense that initially poorer children had greater gains in health care (a greater increase in PHI ownership and a lower reduction in medicine use). Despite this improvement among the poorest, apparently, the Brazilian public health service seems to fail to ensure equity in health care use among children, with possible long-term consequences on inequalities in health. Highlights • The inequities in health care have their beginnings even in early childhood. • Income and mother's education have a strong contribution in the inequalities. • Private health insurance has strong contribution in inequalities of medicine use. • There was reduction in inequity for children's health care in Pelotas/Brazil. • This improvement for poorest children occurred when they reached 72 months. [ABSTRACT FROM AUTHOR]

Abstract Deferred Action for Childhood Arrivals (DACA) recipients face an uncertain fate as their future in the United States is being debated. Yet even before the program was introduced in June 2012 and became endangered in September 2017, they encountered challenges in navigating a fragmented health care landscape throughout the United States. This paper focuses on DACA recipients' experiences in accessing health care throughout their lives, both before and after receiving DACA. We conducted semi-structured interviews and questionnaires with 30 DACA recipients living in Maryland between April–December 2016. Participants represented 13 countries of origin and ranged in age between 18 and 28. Results demonstrate that DACA recipients have had punctuated coverage throughout their lives and continue to face constrained access despite temporary gains in status. Health care access is further stratified within their mixed-status families. Participants have also experienced shifts in their health care coverage due to moving between jurisdictions with variable eligibility and changing life circumstances related to family, school, and employment. This article underscores the importance of examining young adult immigrants' access to care over time as they weather changes in the broader policy context and in highly variable contexts of reception nationwide, shaped by state, but also county and city policies and programs. The challenges and gaps in coverage DACA recipients face also underscore the need for both health care and immigration reform. Highlights • Unique focus on DACA recipients' changing access to and engagement with health care. • Contextualizes DACA recipients' health in reference to family, school, and work. • Describes the impact of fragmented access to care on DACA recipients' lives. • Highlights implications of variable state and local health policies for immigrants. [ABSTRACT FROM AUTHOR]

Abstract The National Health Service in the UK is set up under the principle of "equal access for equal need", where those with identical medical needs should be given equal priority in receiving health care. However, non-medical needs may also be relevant in health care decision-making. This paper considers how members of the general public value access to a health service given equal medical needs, where some service users have additional non-medical needs. There are three primary research questions. First, are public preferences regarding access to a health care service symmetric and inequality averse? Second, are public preferences asymmetric across different needs groups? And third, which individual characteristics of respondents are predictive of different public preferences in this domain? An online survey of the UK general public was conducted in January 2017 using binary choice questions. The hypothetical scenarios involved allocating extra resources from a social perspective, to reduce the waiting time to access a mental health service for the unemployed, for the employed, or for both groups. Based on a valid sample of 662 respondents, the study found that the three main preference categories were: inequality averse and symmetric, inequality averse and asymmetric in favour of the unemployed, and inequality seeking and asymmetric in favour of the unemployed, with the first group being the largest. Respondents' current labour market status was found to explain their preferences so that those who were currently job-seeking were more likely to demonstrate preferences that favoured the unemployed, and those who were currently unemployed were less likely to demonstrate asymmetric preferences that favoured the employed. The implications from these findings are that health policies in the UK that support equal access for equal medical need are likely to be received most favourably, yet a non-trivial minority may support policies favouring those with other, non-medical needs. Highlights • We elicit public preferences on equality of access to a mental health care service. • Preferences are elicited based on equal medical but unequal employment needs. • The modal preference observed was equal access for equal medical need. • Where preferences deviated from symmetry, support was greater for the unemployed. • Current labour market status significantly influenced stated preferences. [ABSTRACT FROM AUTHOR]

Abstract In June 2011, the Government of Ethiopia introduced a pilot Community Based Health Insurance (CBHI) scheme in rural parts of the country. Based on a fixed effects analysis of household panel data, this paper assesses the impact of the scheme on utilization of modern healthcare and the cost of accessing healthcare. It adds to the relatively small body of work that provides a rigorous evaluation of CBHI schemes. We find that in the case of public health facilities, enrolment leads to a 30–41% increase in utilization of outpatient care, a 45–64% increase in the frequency of visits and at least a 56% decline in the cost per visit. The impact on utilization and costs combined with a high uptake rate of almost 50% within two years of scheme establishment underlines the relative success of the Ethiopian scheme. While there are several reasons for this success, a comparative analysis of the design and execution of the Ethiopia CBHI with the existing body of work yields two distinct features. First, the Ethiopian scheme is embedded within existing government administrative structures and to signal government commitment, scheme performance and uptake is used as a yardstick to measure the success of the administration. Second, an existing social protection scheme was used to spread information, raise scheme awareness and encourage uptake of health insurance. The alignment of the interests of administrators with scheme performance and interlinking of social protection schemes are innovative design features that are worth considering as developing countries strive to enhance access to health care through voluntary insurance schemes. Highlights • Ethiopia's pilot community based health insurance scheme enhances health care use. • The scheme also enhances financial protection. • Scheme enrolees experience a 30 to 41 percent increase in health care utilization. • Scheme enrolees experience, at least, a 56 percent decline in cost per visit. • Scheme uptake and effects are promising from a universal health coverage perspective. [ABSTRACT FROM AUTHOR]

Abstract: Explicit health care rationing or priority-setting is the use of institutional procedures for the systematic allocation of resources within health care systems. With the establishment of priority setting systems in various countries in the past two decades, research has been conducted on their principles, methods and institutional aspects. This paper draws on the sociology of science and technology to propose an uncertainty-focused conceptual model of the relationship between knowledge practises and political processes in health care rationing. Taking a case-study approach, the paper explores the public controversy about whether dementia drugs should be available on the UK National Health Service. It shows how three aspects of the controversy – loose institutional framing, open membership and hybrid knowledge – worked together to enable the use of a ‘pragmatic balance’ between rules and cases. Placing this outcome within the space of possibilities suggested by the model, the paper suggests that accepting and fostering the exploration of uncertainty at the core of health care priority setting systems should provide those systems with increased social robustness. [Copyright &y& Elsevier]

Abstract: There is increasing interest in using electronic mail and other electronic health technologies (e-health technologies) in patient follow-ups. This study sheds light on patients’ reception of provider-initiated e-health in their everyday environments. In a research project carried out in Norway (2005–2007), an electronic address for a hospital dermatology ward was offered to 50 patient families for improved access to expert advice from the patients’ homes. Drawing on semi-structured interviews with 12 families, this paper explores how the electronic address was integrated into everyday health practice. The research illuminates how the electronic address did not only represent changes related to treatment procedures and frequency or nature of expert contact; it was also important to other practices in the everyday lives of the families of patients with chronic illness. Once in place on the patients’ computers, the electronic address was ascribed at least four different roles: it was used as the intended riverbed for a flow of information, but also as a safety alarm, as a shield to the medical gaze and as a token of competence in care and parenting. The multiplicity in use and reception of an electronic address in patient settings illustrates the need to include patients’ everyday practices in current professional and political discussions of e-mail and other e-health technologies. Thus this paper argues that there is a need for research on electronic patient–provider communication that moves beyond frequency of use and questions on how technology will affect medical encounters. Social science equally needs to investigate how provider-initiated e-health technologies gets involved in patients’ moral and social performance of health and illness in everyday life. [Copyright &y& Elsevier]

Abstract: The high rate of maternal mortality in Timor-Leste is a persistent problem which has been exacerbated by the long history of military occupation and ongoing political crises since independence in 1999. It is similar to other developing countries where there have been slow declines in maternal mortality despite 20 years of Safe Motherhood interventions. The national Ministry of Health, United Nations (UN) agencies and non-government organisations (NGOs) have attempted to reduce maternal mortality by enacting policies and interventions to increase the number of births in health centres and hospitals. Despite considerable effort in promoting facility-based delivery, most Timorese women birth at home and the lack of midwives means few women have access to a skilled birth attendant. This paper investigates factors influencing access to and use of maternal health services in rural areas of Timor-Leste. It draws on 21 interviews and 11 group discussions with Timorese women and their families collected over two periods of fieldwork, one month in September 2006 and five months from July to December 2007. Theoretical concepts from anthropology and health social science are used to explore individual, social, political and health system issues which affect the way in which maternal health services are utilised. In drawing together a range of theories this paper aims to extend explanations around access to maternal health services in developing countries. An empirically informed framework is proposed which illustrates the complex factors that influence women’s birth choices. This framework can be used by policy-makers, practitioners, donors and researchers to think critically about policy decisions and where investments can have the most impact for improving maternal health in Timor-Leste and elsewhere. [Copyright &y& Elsevier]

Abstract: One way of reducing maternal mortality in developing countries is to ensure that women have a referral system at the local level that includes access to emergency obstetric care. Using a 13-month ethnographic study from 2003 to 2005 of women’s social positions and maternal health in a semi-urban community of Hindu-caste women in the Kathmandu Valley, this paper identifies impediments to receiving obstetric care in a context where the infrastructure and services are in place. As birth in Nepal predominantly takes place at home, this paper identifies the following areas for potential improvement in order to avoid the loss of women’s lives during childbirth: the frequency of giving birth unaided, minimal planning for birth or obstetric complications, and delayed responses at the household level to obstetric emergencies. Focusing particularly on the last item, this study concludes that women do not have the power to demand biomedical services or emergency care, and men still viewed birth as the domain of women and remained mostly uninvolved in the process. As the cultural construction of birth shifts from a “natural” phenomenon that did not require human regulation toward one that is located within the domain of biomedical expertise and control, local acceptance of a biomedical model does not necessarily lead to the utilization of services if neither women nor men are in a culturally-defined position to act. [Copyright &y& Elsevier]