Caring During COVID-19: A Study of Intersectionality and Inequities in the Care Economy in 16 Countries.

Carers were disproportionately harmed in the COVID-19 pandemic. Despite facing an increased risk of contracting the virus, they continued in frontline roles in care services and acted as "shock absorbers" for their families and communities. In this article, we apply an intersectional lens to examine care work and the structural factors disadvantaging carers during COVID-19 through a comparative case study analysis of 16 low-, middle-, and high-income countries. Data on each country was collected through a qualitative framework during 2021-2022. We found that while carers everywhere were predominantly women with low incomes and precarious employment, other factors were at play in shaping their experiences. Moreover, government responses to mitigate the direct impact of the pandemic have created local and global disparities affecting those working in this sector. Our findings reveal how oppressive social structures such as race, class, caste, and migration status converged in contextually specific ways to shape the gendered nature of care within and between different countries. We call for a better understanding of the multiple axes of inequalities experienced by carers to inform crisis mitigations, coupled with long-term strategies to address social inequities in the care economy and to promote gender equality.

The management of cognitive labour in same-gender couples.

OBJECTIVE: This study explored how cognitive labour as a form of unpaid, household labour is performed by people in same-gender couples. BACKGROUND: Excessive performance of unpaid labour has been associated with several health impacts. Cognitive labour (anticipating needs, identifying options for meeting needs, making decisions and monitoring progress) is an underexamined dimension of unpaid labour which has centered on the experiences of heterosexual couples. METHOD: Dyadic and individual interviews were carried out to explore how cognitive labour was performed in same-gender couples between March and October 2021 using an inductive methodology. Adults who were in a same-gender couple, had lived with their partner for at least six months, were not living with children were recruited largely via social media. RESULTS: Examining cognitive labour performance amongst same-gender couples revealed four key themes: 1) habitually fostered patterns of trust; 2) agency in redefining family; 3) barriers to cognitive harmony; and 4) facilitators to cognitive harmony. Findings regarding the relationships between themes are presented in a narrative model. Dyadic interviews allowed for deep, narratives relating to cognitive labour performance. CONCLUSIONS: The narrative model provides new conceptual understanding of how cognitive labour is performed outside of the heteronormative sphere. Couple's adoption of a strengths-based frame to cognitive labour performance removed the opposition inherent in gender dichotomies. These findings support calls for research to incorporate social change to build and refine theory, including how queer and feminist movements have challenged gendered and heteronormative family and household roles.

Illustrating the impact of commercial determinants of health on the global COVID-19 pandemic: Thematic analysis of 16 country case studies.

Previous research on commercial determinants of health has primarily focused on their impact on non-communicable diseases. However, they also impact on infectious diseases and on the broader preconditions for health. We describe, through case studies in 16 countries, how commercial determinants of health were visible during the COVID-19 pandemic, and how they may have influenced national responses and health outcomes. We use a comparative qualitative case study design in selected low- middle- and high-income countries that performed differently in COVID-19 health outcomes, and for which we had country experts to lead local analysis. We created a data collection framework and developed detailed case studies, including extensive grey and peer-reviewed literature. Themes were identified and explored using iterative rapid literature reviews. We found evidence of the influence of commercial determinants of health in the spread of COVID-19. This occurred through working conditions that exacerbated spread, including precarious, low-paid employment, use of migrant workers, procurement practices that limited the availability of protective goods and services such as personal protective equipment, and commercial actors lobbying against public health measures. Commercial determinants also influenced health outcomes by influencing vaccine availability and the health system response to COVID-19. Our findings contribute to determining the appropriate role of governments in governing for health, wellbeing, and equity, and regulating and addressing negative commercial determinants of health.

Through the wine glass: How biographical midlife transitions and women's affective interpretations interact with alcohol consumption.

BACKGROUND: Women during midlife are consuming larger quantities of alcohol than any other age group of women and any other generation of midlife women previously. This is concerning given alcohol related-health risks coalesce with age-related health risks for women, in particular, breast cancer. METHODS: In-depth interviews with 50 Australian midlife women (aged 45-64) from different social classes explored women's personal accounts of midlife transitions and their descriptions of the role of alcohol in navigating these life experiences; both daily occurrences as well as significant moments in the life course. RESULTS: Our findings point to the complex, confusing and co-existing biographical transitions women experience during midlife (generational, embodied/physiological and material changes) that sharpen a role for alcohol in women's lives and are nuanced by social class (volumes of social, economic and cultural capital). We pay close attention to women's affective interpretations of these transitions and ways alcohol is used to feel robust in navigating daily life or easing their prospective futures. Critically, for women living with limited access to capital, and who could not 'measure up' to social ideals by comparison with the achievements and trajectories of other midlife women, alcohol reconciled their disappointment. Our exploration shows how the social class conditions that shape how women make sense of their transitions through midlife might be differently shaped to enable different options forreducing drinking. CONCLUSIONS: Policy must address the social and emotional concerns women experience through midlife transitions that give alcohol a worthwhile place in their lives. A first step might be responding to the absence of community and leisure spaces for midlife women especially those that do not integrate alcohol, with benefits including addressing loneliness, isolation and feeling invisible, and enabling positive constructions of midlife identities. Structural barriers to participation and feelings of worth must be removed for women who lack social, cultural and economic resources.

Reviving health promotion in South Australia: The role of ideas, actors and institutional forces.

Globally health promotion has remained marginalized while biomedical health systems have maintained and even increased their dominance. During 2019-2021 we drew on the local and historical knowledge of actors from multiple sectors through semi-structured interviews and focus groups, to assess the implications of the withdrawal of the state from health promotion in a suburban region of South Australia. Institutional theory enabled in-depth analysis of the ideas, actors, and institutional forces at play in the institutional field, and how these elements come together to maintain the dominance of medicine. We found that the ideas, actors and institutional forces supporting health promotion in the study region have weakened and fragmented. This has happened as biomedicine has increased its dominance in the region's health system, mirroring international trends. The results point to a withdrawal of state and federal governments from health promotion, which has led to severe gaps in leadership and governance, and locally, to a decline in capacity and resources. The state health department reallocated resources to focus on individual behavioural change rather than more structural factors affecting health. While some activities aimed at the social determinants of health or community development strategies remained, these had minimal institutional support. The establishment of a state government wellbeing agency in 2020 prompted an exploration to determine whether the agency and the international wellbeing movement presents an opportunity for a revival of more comprehensive health promotion.

Health promotion has a rich history in South Australia. However, since government withdrew funding and institutional support, health promotion has become increasingly fragmented, unco-ordinated and targeted towards individual behaviour change activities. Analysis of the role of ideas, actors, and institutional forces, such as government policies, found that biomedical approaches to health and health care increasingly dominate the health system and health policy environment in the state and Australia wide. The establishment of a state government wellbeing agency in 2020 prompted optimism from participants that the government may once again take a leadership role in reviving health promotion and prevention strategies.

Explaining health inequalities in Australia: the contribution of income, wealth and employment.

BACKGROUND: Studies show widespread widening of socioeconomic and health inequalities. Comprehensive primary health care has a focus on equity and to enact this requires more data on drivers of the increase in inequities. Hence, we examined trends in the distribution of income, wealth, employment and health in Australia. METHODS: We analysed data from the Public Health Information Development Unit and Australian Bureau of Statistics. Inequalities were assessed using rate ratios and the slope index of inequality. RESULTS: We found that the social gradient in health, income, wealth and labour force participation has steepened in Australia, and inequalities widened between the quintile living in the most disadvantaged areas and the quintile living in the least disadvantaged areas. CONCLUSION: Widening income, wealth and employment inequalities have been accompanied by increasing health inequalities, and have reinforced and amplified adverse health effects, leading to increased mortality inequality. Effective comprehensive primary health care needs to be informed by an understanding of structural factors driving economic and health inequities.

Conducting a rapid health promotion audit in suburban Adelaide, South Australia: Can it contribute to revitalising health promotion?

ISSUES ADDRESSED: How health promotion is implemented varies and it is often not clear what activities are in place in a region. Understanding the extent of health promotion activities helps planning activities. METHODS: This research involved a rapid audit of the types of health promotion activities in a suburban region of South Australia. This analysis was guided by the WHO Ottawa Charter's principles. To better understand population needs and which health promoting activities may help, an epidemiological, demographic and social determinants of health profile of southern Adelaide described disease patterns and health inequities. RESULTS: While there was evidence of a range of health promoting activities, most concerned individual or behavioural services. A key finding was the small number of activities that the state health department and local health system were responsible for. Alongside local government, NGOs provided the bulk of health promotion activities. In addition, there were no overarching health promotion strategies or coordinating bodies to evaluate the activities. The epidemiological, demographic and social determinants of health profile found persistent health and social inequities. CONCLUSION: This rapid audit of health promotion in a region enabled a quick assessment of the current health promotion situation and provided evidence of gaps and areas where policy change should be advocated. SO WHAT?: The key findings distilled from this research were designed to inform policy priorities to shift health promotion in southern Adelaide onto a trajectory consistent with the Ottawa Charter and prevent further focus on individualised behaviour change strategies known as 'lifestyle drift'.

Gender Equality and the Global Gender Gap in Life Expectancy: An Exploratory Analysis of 152 Countries.

When looking at life expectancy (LE) by sex, women live longer than men in all countries. Biological factors alone do not explain gender differences in LE, and examining structural differences may help illuminate other explanatory factors. The aim of this research is to analyse the influence of gender inequality on the gender gap in LE globally. We have carried out a regression analysis between the gender gap in relativised LE and the UN Gender Inequality Index (GII), with a sensitivity analysis conducted for its three dimensions, stratified by the six World Health Organization (WHO) regions. We adjusted the model by taking into consideration gross national income (GNI), democratic status and rural population. The results indicated a positive association for the European region (ß=0.184) and the Americas (ß=0.136) in our adjusted model. Conversely, for the African region, the relations between gender equality and the LE gender gap were found to be negative (ß=-0.125). The findings suggest that in the WHO European region and the Americas, greater gender equality leads to a narrowing of the gender LE gap, while it has a contrary relationship in Africa. We suggest that this could be because only higher scores in the GII between men and women show health benefits.

New Perspective on Why Women Live Longer Than Men: An Exploration of Power, Gender, Social Determinants, and Capitals.

BACKGROUND: Women live longer than men, even though many of the recognised social determinants of health are worse for women than men. No existing explanations account fully for these differences in life expectancy, although they do highlight the complexity and interaction of biological, social and health service factors. METHODS: this paper is an exploratory explanation of gendered life expectancy difference (GLED) using a novel combination of epidemiological and sociological methods. We present the global picture of GLED. We then utilise a secondary data comparative case analysis offering explanations for GLED in Australia and Ethiopia. We combine a social determinant of health lens with Bourdieu's concepts of capitals (economic, cultural, symbolic and social). RESULTS: we confirmed continuing GLED in all countries ranging from less than a year to over 11 years. The Australian and Ethiopian cases demonstrated the complex factors underpinning this difference, highlighting similarities and differences in socioeconomic and cultural factors and how they are gendered within and between the countries. Bourdieu's capitals enabled us to partially explain GLED and to develop a conceptual model of causal pathways. CONCLUSION: we demonstrate the value of combing a SDH and Bourdieu's capital lens to investigate GLED. We proposed a theoretical framework to guide future research.

Why do some countries do better or worse in life expectancy relative to income? An analysis of Brazil, Ethiopia, and the United States of America.

BACKGROUND: While in general a country's life expectancy increases with national income, some countries "punch above their weight", while some "punch below their weight" - achieving higher or lower life expectancy than would be predicted by their per capita income. Discovering which conditions or policies contribute to this outcome is critical to improving population health globally. METHODS: We conducted a mixed-method study which included: analysis of life expectancy relative to income for all countries; an expert opinion study; and scoping reviews of literature and data to examine factors that may impact on life expectancy relative to income in three countries: Ethiopia, Brazil, and the United States. Punching above or below weight status was calculated using life expectancy at birth and gross domestic product per capita for 2014-2018. The scoping reviews covered the political context and history, social determinants of health, civil society, and political participation in each country. RESULTS: Possible drivers identified for Ethiopia's extra 3 years life expectancy included community-based health strategies, improving access to safe water, female education and gender empowerment, and the rise of civil society organisations. Brazil punched above its weight by 2 years. Possible drivers identified included socio-political and economic improvements, reduced inequality, female education, health care coverage, civil society, and political participation. The United States' neoliberal economics and limited social security, market-based healthcare, limited public health regulation, weak social safety net, significant increases in income inequality and lower levels of political participation may have contributed to the country punching 2.9 years below weight. CONCLUSIONS: The review highlighted potential structural determinants driving differential performance in population health outcomes cross-nationally. These included greater equity, a more inclusive welfare system, high political participation, strong civil society and access to employment, housing, safe water, a clean environment, and education. We recommend research comparing more countries, and also to examine the processes driving within-country inequities.

How do advisory groups contribute to healthy public policy research?

OBJECTIVES: This paper reflects on experiences of Australian public health researchers and members of research policy advisory groups (PAGs) in working with PAGs. It considers their benefits and challenges for building researcher and policy actor collaboration and ensuring policy relevance of research. METHODS: Four research projects conducted between 2015 and 2020 were selected for analysis. 68 PAG members from Australian federal, state and local governments, NGOs and academics participated in providing feedback. Thematic analysis of participant feedback and researchers' critical reflections on the effectiveness and capacity of PAGs to support research translation was undertaken. RESULTS: PAGs benefit the research process and can facilitate knowledge translation. PAG membership changes, differing researcher and policy actor agendas, and researchers' need to balance policy relevance and research independence are challenges when working with PAGs. Strategies to improve the function of health policy research PAGs are identified. CONCLUSIONS: The paper suggests a broader adapted approach for gaining the benefits and addressing the challenges of working with PAGs. It opens theoretical and practical discussion of PAGs' role and how they can increase research translation into policy.

Global health activists' lessons on building social movements for Health for All.

BACKGROUND: The People's Health Movement (PHM) was formed in 2000 and drew inspiration from the Alma Ata Declaration on Primary Health Care's 'Health for All' (1978). Since then PHM has been an active part of a global counter-hegemonic social movement. This study aimed to gain insights on social movement building, drawing on the successes and failures reported by activists over their experiences of working in the Health for All social movement to improve health, justice and equity. METHODS: Qualitative research methods were employed in this study to capture complex and historical narratives of individual activists, through semi-structured interviews and subsequent thematic analysis of transcripts. The research design and analysis were informed by social movement theory and literature on health activism as a pathway for social change. In this study we examine the semi-structured interviews of 15 health activists who are part of the PHM, with the aim of deriving lessons for strengthening movements for Health for All. RESULTS: This study locates the activists' narratives within a socio-political analysis of the global trends of late modern individualism and capitalist neoliberalism. This highlights the challenges faced by civil society groups mobilising collective action and building social movements for Health for All. The study found that within the constraints of the neoliberal socio-political and economic conditions which have caused the rise in social and health inequities, this group of long-term health activists have been nurturing alternative approaches to structuring society and building collective agency to improve health. CONCLUSION: The practical long-term experiences of the PHM activists examined in this study contribute to a better understanding of the processes and motivations that lead to and sustain health activism, and the dilemmas, strategies, impacts and achievements of such activism.

Embodiment as a Paradigm for Understanding and Treating SE-AN: Locating the Self in Culture.

There has been a growing call for sociologically engaged research to better understand the complex processes underpinning Severe and Enduring Anorexia Nervosa (SE-AN). Based on a qualitative study with women in Adelaide, South Australia who were reluctant to seek help for their disordered eating practices, this paper draws on anthropological concepts of embodiment to examine how SE-AN is experienced as culturally grounded. We argue that experiences of SE-AN are culturally informed, and in turn, inform bodily perception and practice in the world. Over time, everyday rituals and routines became part of participants' habitus', experienced as taken-for-granted practices that structured life-worlds. Here, culture and self are not separate, but intimately entangled in and through embodiment. Approaching SE-AN through a paradigm of embodiment has important implications for therapeutic models that attempt to move anorexia nervosa away from the body and separate it from the self in order to achieve recovery. Separating experiences-literally disembodying anorexia nervosa-was described by participants as more than the loss of an identity; it would dismantle their sense of being-in-the-world. Understanding how SE-AN is itself a structure that structures every aspect of daily life, helps us to understand the fear of living differently, and the safety that embodied routines bring. We conclude by asking what therapeutic treatment might look like if we took embodiment as one orientation to SE-AN, and focused on quality of life and harm minimization.

Punching above their weight: a network to understand broader determinants of increasing life expectancy.

BACKGROUND: Life expectancy initially improves rapidly with economic development but then tails off. Yet, at any level of economic development, some countries do better, and some worse, than expected - they either punch above or below their weight. Why this is the case has been previously researched but no full explanation of the complexity of this phenomenon is available. NEW RESEARCH NETWORK: In order to advance understanding, the newly formed Punching Above Their Weight Research Network has developed a model to frame future research. It provides for consideration of the following influences within a country: political and institutional context and history; economic and social policies; scope for democratic participation; extent of health promoting policies affecting socio-economic inequities; gender roles and power dynamics; the extent of civil society activity and disease burdens. CONCLUSION: Further research using this framework has considerable potential to advance effective policies to advance health and equity.

Positioning relapse and recovery through a cultural lens of desire: A South Australian case study of disordered eating.

This article explores how desire operates in the daily lives of women with disordered eating. Based on qualitative findings from a South Australian study investigating why women with disordered eating are reluctant to seek help, we trace the multiple "tipping points" and triggers that are central to participants' everyday experiences. Employing anthropological interpretations of desire, we argue that triggers are circulations of productive desire, informed by cultural values and social relations, and embodied in routine daily acts. We examine the cultural-work of desire and the ways in which gendered relationships with food, eating and bodies trigger desires, creating a constant back and forth movement propelling participants in multiple directions. In conclusion, we suggest that a socio-cultural approach to desire in disordered eating has clinical implications, as cultural configurations of desire may help to understand ambivalence towards relapse and recovery.