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Interactions in the healthcare system today involve an important new set of actors: evaluative health platforms (EHPs). These platforms are not neutral intermediaries, but active moderators of how patients express opinions, choose providers, and consume health-related information. This paper adds to our understanding of the varied and evolving commercial interests of EHPs and the implications these have for patient voice. We analyze 71 platforms in the USA, UK, and Germany and identify five ideal types: subscribers, analyzers, advertisers, regulators, and scammers. Each platform type enacts a unique competitive strategy through an evaluative infrastructure which constrains but also generates possibilities for patient voice. Based on our typology, we develop three contributions. First, we nuance universalizing claims about the consequences of platform capitalism by specifying the diverse strategies underpinning competition between EHPs in different countries, and showing how each strategy leads evaluative infrastructures to develop in ways that impact patient voice. Second, we show how patients can navigate the challenges of a complex EHP space by exercising their ability to choose between platforms. Finally, we outline the conditions platforms need to fulfil to become empowering. Overall, this study highlights the varied and complex relationship between platform business models and user voice, which exists not only in healthcare, but also in many other fields. • Typology of evaluative health platforms (EHPs) in the US, the UK, and Germany. • EHP business models and content moderation techniques vary considerably. • EHPs have a wide range of implications for patient voice. • More transparency and competition can help platforms increase patient empowerment. [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]

Abstract Local public health authorities often lack the capacity to adapt to climate change, despite being on the 'front lines' of climate impacts. Upper-level governments are well positioned to create an enabling environment for adaptation and build local public health authorities' capacity, yet adaptation literature has not specified how upper-level governments can build local-level adaptive capacity. In this paper we examine how federal and regional governments can contribute to enabling and supporting public health adaptation to climate change at the local level in federal systems. We outline the local level's self-assessed adaptive capacity for public health adaptation in Canadian and German comparative case studies, in terms of funding, knowledge and skills, organizations, and prioritization, drawing upon 30 semi-structured interviews. Based on interviewees' recommendations and complemented by scientific literature, we develop a set of practical measures that could enable or support local-level public health adaptation. We find that adaptive capacity varies widely between local public health authorities, but most report having insufficient funding and staff for adaptation activities. We propose 10 specific measures upper-level governments can take to build local public health authorities' capacity for adaptation, under the interrelated target areas of: building financial capital; developing and disseminating usable knowledge; collaborating and coordinating for shared knowledge; and claiming leadership. Federal and regional governments have an important role to play in enabling local-level public health adaptation, and have many instruments available to them to fulfill that role. Selecting and implementing measures to enable local public health authorities' adaptive capacity will require tailoring to, and consideration, of the local context and needs. Highlights • Local public health authorities often lack capacity to adapt to climate change. • National and regional governments can play supportive or enabling role. • We propose 10 concrete measures to enable local public health adaptation. [ABSTRACT FROM AUTHOR]

This paper examines the role of perceived disease risk in vaccination behavior. Using health insurance claims data, I estimate the effect of local measles outbreaks in Germany on first- and second-dose measles vaccinations in children as well as catch-up vaccinations in adults. In my analytic strategy, I exploit the variation in timing and location of regional disease outbreaks and estimate a two-way fixed effects model with birth cohort and region fixed effects. The basic underlying assumption is that measles outbreaks alter perceptions regarding the disease risk. The robustness of this approach concerning possible bias due to heterogeneous treatment effects under differential treatment timing is assessed through the use of alternative estimators. Measles outbreaks within a region increase the share of children who receive their vaccination on time by 0.8 percentage points for both the first and second vaccination. This corresponds to a reduction in the share of not timely vaccinated children of about 1.0% and 1.6% for the first and second doses, respectively. Results further show an increase in the rate of monthly catch-up vaccinations in adults by about 10% for the age group 20–30 to up to 46% for those at ages 40–50 in the first six months after an outbreak. One important finding is that regional outbreaks do not lead to increases in vaccinations in other regions even if public attention extends beyond the affected region. These results suggest that behavioral responses are driven by affective rather than deliberative risk perception. Also, vaccination effects can be observed only in the few months following the outbreak, which indicates that changes in the perceived disease risk due to a local measles outbreak are short-lived and fade away quickly once the disease outbreak is over. • Measles outbreaks increase the share of children with on-time measles vaccination. • Outbreaks affect the timing, though not the overall long-term vaccination coverage. • Measles outbreaks also increase the rate of monthly catch-up vaccinations in adults. • Vaccination effects are observed only in the few months following an outbreak. [ABSTRACT FROM AUTHOR]

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

Previous studies have found poverty to be related to lower levels of health due to poor health behavior such as unhealthy eating, smoking or less physical activity. Longer periods of poverty seem to be especially harmful for individual health behavior. Studies have shown that poverty has a dynamic character. Moreover, poverty is increasingly regarded as being a multidimensional construct and one that considers more aspects than income alone. Against this background this paper analyzes the relationship between health behavior and persistent spells of income poverty as well as a combined poverty indicator using data of the German Socio-Economic Panel (2000–2010). Next to cross-sectional logistic regression models we estimate fixed-effects models to analyze the effect of persistent poverty on dietary behavior, tobacco consumption, and physical activity. Cross-sectional results suggest that persistent poverty is related to poor health behavior, particularly regarding tobacco consumption and physical activity. Results also show that multidimensional and dynamic aspects of poverty matter. Complementary panel analyses reveal negative effects for the combined poverty indicator only for dietary behavior in the total sample. However, by analyzing the sample by gender we identify further effects of persistent poverty on health behavior. The analyses show that not only do individuals in poverty but also those in precarious situations show health-damaging behavior more often. [ABSTRACT FROM AUTHOR]

Attention Deficit Hyperactivity Disorder (ADHD) has been medicalized in the United States since the 1960s. Primarily used in North America until the 1990s, ADHD diagnosis and treatment have increasingly been applied internationally. After documenting the expansion of ADHD in a global context, this paper presents five brief international examples examining ADHD usage and expansion: the United Kingdom, Germany, France, Italy and Brazil. We then identify and describe several vehicles that facilitate the migration of the ADHD diagnosis: the transnational pharmaceutical industry; the influence of western psychiatry; moving from ICD to DSM diagnostic criteria; the role of the Internet including the related advent of easily accessible online screening checklists; and advocacy groups. Finally, we discuss what this globalization of a diagnosis reflects about the potential global medicalization of other conditions. [ABSTRACT FROM AUTHOR]

In this paper, I critically investigate humanitarian aid for migrant populations in Germany. I aim to enhance the existing literature on migrant deservingness and humanitarian aid by focusing on the performative aspects of concrete face-to-face interactions between physicians/volunteers and patients. I argue that despite efforts of volunteers to provide non-discriminatory care, the encounters between patients as aid-receivers and volunteers/physicians as aid-providers are inevitably shaped by power inequalities. These immanent power inequalities may lead patients to perform their deservingness, that is, to present themselves as helpless sufferers rather than empowered subjects. Simultaneously, patient-solicitants are prevented from feeling and enacting a sense of entitlement. Those patients who do not heed to the social mechanisms of humanitarian aid, such as being thankful and humble, cause disenchantment on the side of some medical professionals who provide care as part of humanitarian networks and subsequently, they may be turned away. The research project focused on the migration trajectories and illness experiences of undocumented Latin American migrants and their access to healthcare. The analysis draws on my long-term ethnographic fieldwork with 35 Latin American migrants in Berlin (2008–2011), 22 interviews with healthcare providers, and my experience as an activist/volunteer for a Berlin-based humanitarian NGO (2008–2012). [ABSTRACT FROM AUTHOR]

Abstract: Despite the increasing number of non-marital romantic relationships in developed countries, little is known about their effects on health-related behaviors. This paper examined the impact of relationship status (single, dating, cohabiting or married) on physical activity. Three possible mechanisms underlying this association were discussed: social control and support by the partner, time restrictions and the release from the marriage market. Data were obtained from the German Socio-Economic Panel (GSOEP), a random sample of individuals living in private households in Germany. Both random-effects and fixed-effects logit models were estimated. The random-effects analyses referred to 30,201 individuals and the fixed-effects analyses referred to 11,568 individuals who were observed for up to 19 years. After adjusting for age, measurement period and the presence of children, fixed-effects estimates showed reduced physical activity for each type of relationship for both men and women. The effects were strongest for married couples and weakest for dating couples, and remained similar after controlling for discretionary time. However, the effects found partly depended on age: for men, the negative impacts of cohabitation and marriage on physical activity became weaker with increasing age and shifted to positive impacts. For women, the negative effect of marriage on physical activity also decreased but stayed negative into old age. The results suggest that the release from the marriage market may cause the negative effects of relationships on physical activity. Social support and social control may play a role in older age, whereas the amount of discretionary time seems to be of minor importance for explaining relationship effects on physical activity. If the results will be validated by other studies there will be valuable implications for health promotion programs. [Copyright &y& Elsevier]

Abstract: Water is one of the most important landscape elements. In settled areas, planners rediscovered urban blue in the form of rivers as a soft location factor in post-industrial times. Although the recognition of the need for recreational or ‘healthy’ places like urban green or urban blue in cities is increasing, current urban planning is mostly conducted without taking beneficial health issues into account. In this paper an extended concept of therapeutic landscapes is used to analyse two promenades on the river Rhine in the centres of two German cities (Cologne and Düsseldorf). A complex of qualitative and quantitative methods from diverse disciplines is applied to obtain a multi-dimensional image of salutogenic health processes. The results show that the promenades are favourite places to spend leisure time and to engage in recreational activities, in addition to providing restoration from everyday stresses. Water is a strong predictor of preference and positive perceptive experiences in urban environments. Users of the promenades also report strong emotional attachments to the place. Urban blue space may be interpreted as a therapeutic landscape in various ways. The study forms a contribution to planning issues, particularly considering benefits for human health, and enhances current research concerning therapeutic landscapes. [Copyright &y& Elsevier]

Abstract: Water is one of the most important landscape elements. In settled areas, planners rediscovered urban blue in the form of rivers as a soft location factor in post-industrial times. Although the recognition of the need for recreational or ‘healthy’ places like urban green or urban blue in cities is increasing, current urban planning is mostly conducted without taking beneficial health issues into account. In this paper an extended concept of therapeutic landscapes is used to analyse two promenades on the river Rhine in the centres of two German cities (Cologne and Düsseldorf). A complex of qualitative and quantitative methods from diverse disciplines is applied to obtain a multi-dimensional image of salutogenic health processes. The results show that the promenades are favourite places to spend leisure time and to engage in recreational activities, in addition to providing restoration from everyday stresses. Water is a strong predictor of preference and positive perceptive experiences in urban environments. Users of the promenades also report strong emotional attachments to the place. Urban blue space may be interpreted as a therapeutic landscape in various ways. The study forms a contribution to planning issues, particularly considering benefits for human health, and enhances current research concerning therapeutic landscapes. [Copyright &y& Elsevier]

Abstract: While empirical evidence continues to show that low socio-economic position is associated with less likely chances of being in good health, our understanding of why this is so remains less than clear. In this paper we examine the theoretical foundations for a structure–agency approach to the reduction of social inequalities in health. We use Max Weber’s work on lifestyles to provide the explanation for the dualism between life chances (structure) and choice-based life conduct (agency). For explaining how the unequal distribution of material and non-material resources leads to the reproduction of unequal life chances and limitations of choice in contemporary societies, we apply Pierre Bourdieu’s theory on capital interaction and habitus. We find, however, that Bourdieu’s habitus concept is insufficient with regard to the role of agency for structural change and therefore does not readily provide for a theoretically supported move from sociological explanation to public health action. We therefore suggest Amartya Sen’s capability approach as a useful link between capital interaction theory and action to reduce social inequalities in health. This link allows for the consideration of structural conditions as well as an active role for individuals as agents in reducing these inequalities. We suggest that people’s capabilities to be active for their health be considered as a key concept in public health practice to reduce health inequalities. Examples provided from an ongoing health promotion project in Germany link our theoretical perspective to a practical experience. [Copyright &y& Elsevier]

Abstract: The recent debate in public health about the “inequality paradox” mirrors a long-standing dispute between proponents of structuralist approaches and advocates of action theory. Both views are genuine perspectives of health promotion, but so far they have not been adequately linked by health promotion theory. Using Anthony Giddens''s concepts of structure and agency seems promising, but his theory has a number of shortcomings that need to be amended if it is to be applied successfully to health promotion. After briefly assessing Giddens’s theory of structuration, this paper proposes to add to it both the concept of structural change as proposed by William Sewell and the policy dimension as described by Elinor Ostrom in her distinction between “operational” and “collective choice” level. On this basis, a multi-level model of the interaction of structure and agency in health promotion is proposed. This model is then connected to central claims of the Ottawa Charter, i.e. “build healthy public policy”, “create supportive environments”, “strengthen community actions”, and “develop personal skills”. A case study from a local-level health promotion project in Germany is used to illustrate the explanatory power of the model, showing how interaction between structure and agency on the operational and on the collective choice level led to the establishment of women-only hours at the municipal indoor swimming pool as well as to increased physical activity levels and improved general self-efficacy among members of the target group. [Copyright &y& Elsevier]

Abstract: This study was the first multilevel analysis to investigate the possible impact of macro-level factors on individual self-rated health over and above individual characteristics across Germany. This is especially interesting against the background of German history and the persistent disparity between Eastern and Western Germany. In this paper, the 439 German administrative districts, called Landkreise, provided the macro-level characteristics for this study. Altogether, 5516 individuals in 437 districts were included from data collected between 2005 and 2007. Our results show a significant association between the district unemployment rate and subjective health. The impact remains significant after adjusting for individual variables, including individual employment status. Furthermore, a significant association was found between subjective health and the degree of rurality, the proportion of elderly inhabitants and the proportion of foreigners. However, the variance of these was zero. In conclusion, our findings indicate an independent association between the unemployment rate of districts and individual self-rated health. Area mechanisms identified for other countries seem to exist in Germany, too, beyond the well-known differences between the Federal Republic of Germany and the German Democratic Republic that still influences individual health outcomes. [Copyright &y& Elsevier]

Abstract: Against the background of the increasing academic and political debate on financial incentives for organ donation, we conducted a qualitative investigation on the conditions under which European citizens would actually consider or refuse financial incentives for organ donation. Our paper combines an analysis of data that were collected in eight Focus Group discussions on transplantation medicine with lay people and patients from four European countries (Cyprus, Germany, the Netherlands, and Sweden) with a critical re-assessment of the dichotomy between gift and commodity in the recent political and academic discourse. We find that the distinction between living and post mortem donation on the one hand, and between different models of financial incentives on the other, plays a crucial role for the participants'' values and ideas about organ donation. We discuss the significance of our results with particular respect to the central role of reciprocity and draw conclusions for the bioethical and biopolitical debate. [Copyright &y& Elsevier]

Abstract: This paper discusses the policy debate and ethical discussion surrounding pre-implantation genetic diagnosis (PGD) for sibling donor (SD) in Germany and Israel. Based on an analysis of the regulations and ethical discourse concerning a unique form of new reproductive technology (NRT)—PGD for SD—we complement the scholarly discussion of NRTs in these countries, by pointing to an explanatory factor that has been so far neglected, namely the hegemonic notions regarding the ideal relationship between the generations, and the mutual obligations between different family members in Germany and Israel. We argue the fact that PGD (in general) and PGD for SD (in particular) have been banned in Germany, but were endorsed without hesitation in Israel, has to do with different perceptions of family ethics within the two societies. Furthermore, we argue that this factor contributes significantly to the more general understanding of German and Israeli policies regarding NRTs. [Copyright &y& Elsevier]

Drug consumption rooms directly attempt to intervene in and govern the place and time of drug use. Whilst the risk-reducing potentials of these interventions have been thoroughly evaluated, the consumption room literature offers fewer insights into the embodied, affective and situated dynamics that underscore service delivery. In this paper, we take up the notion of atmosphere to explore these dynamics in greater depth. Drawing on 12 months of ethnographic research in a German drug consumption room, we describe the manner in which atmospheres came to pervade and condition service encounters. More than simply providing texture to activities within the consumption room, we show how atmospheres gave rise to a distinct range of bodily capacities and therapeutic effects. Critically, these atmospheric affordances exceeded the risk-reducing objectives of the consumption room to encompass an emergent capacity to find repose, enact respite and foster modes of sociality and care. Our analysis further highlights the contextual contingencies through which the atmospheres of the consumption room emerged, including the efforts of both staff and clients to cultivate and control particular atmospheric qualities. We conclude by considering how closer attention to the atmospheric and affective dimensions of service delivery may challenge how consumption room interventions are enacted, valued and researched. This is to gesture towards a novel, atmospheric mode of harm reduction that has effects by transforming embodied potentials for both staff and clients. • Uses ethnography to explore the atmospheric dimensions of a drug consumption room. • Describes how atmospheres emerge through and shape service encounters. • Analyses how atmospheres mediate the expression of care and support. • Shows how staff and clients cultivate and control particular atmospheric qualities. • Gestures towards the possibilities of and for an atmospheric harm reduction. [ABSTRACT FROM AUTHOR]

Previous studies suggest injunctive norms (prompts of what people ought to do) are stronger predictors of healthy eating intentions, whereas descriptive norms (prompts of what people are doing) are stronger predictors of healthy eating behaviors. However, previous research provides little insight into why different norms influence children's health intentions and behaviors differently. In addition, no research has explored developmental differences in children's conformity to, or rejection of, different types of social normative influence. Thus, this paper adopts a developmental perspective to understand why children conform differently to descriptive and injunctive norm messaging on healthy eating. An experiment was done with 405 children in Germany aged 7 to 16. The research design was a 4 (social norms: descriptive vs. injunctive peer vs. injunctive authority vs. control) × 2 (developmental stage: middle childhood vs. adolescence) between-subject design. Children's healthy eating intentions and behaviors were collected as key dependent variables. and conclusions: The experimental results suggest that children mainly use a descriptive norm as an information shortcut to behaving "appropriately". This should have a stronger impact on younger children than older ones, although both young and old children consider it easier to understand than an injunctive norm. The experimental results further suggest that an injunctive norm mainly influences children via activation of a motive for maintaining a positive self-image in public, rather than one of affiliation. These results are very important for social research on health, because they can explain why different social norms influence health intentions and behaviors differently. In addition, our finding that injunctive norm conformity is mainly used for impression management purposes can reconcile existing contradictory results on the impact of social norms on children. • Study exposed children of different age to different norms. • Only descriptive norms influence young children's snack choice behavior. • Injunctive authority norms increase young children's eating intentions , not behavior. • Injunctive authority norms make adolescents less likely to eat healthily. [ABSTRACT FROM AUTHOR]

This paper analyzes whether education has a protective effect on mental health. To estimate causal effects, we employ an instrumental variable (IV) technique that exploits a reform extending compulsory schooling by one year implemented between 1949 and 1969 in West Germany. We complement analyses on the Mental Component Summary (MCS) score as a generic measure of overall mental health with an MCS-based indicator for risk of developing symptoms of mental health disorder and a continuous measure of subjective well-being. Results support existing evidence of a positive relationship between completed years of secondary schooling and mental health in standard OLS estimations. In contrast, the IV estimations reveal no such causal protective effect and negative effects cannot be ruled out. • We study whether education has a causal protective effect on mental health. • We use a compulsory schooling reform in Germany as a source of exogenous variation. • We measure mental health by the MCS score and subjective well-being from SOEP data. • We find no evidence for a causal protective effect. • Our results are robust to various specifications. [ABSTRACT FROM AUTHOR]