Digital geographies of care: Telehealth landscapes of addiction treatment during the COVID-19 pandemic.

The COVID-19 pandemic has created new digital health care landscapes for the management of substance use and misuse. While telehealth was prohibited for addiction treatment prior to the pandemic, the severity of COVID-19 precipitated telehealth expansion for the delivery of individual and group-based treatment. Research has highlighted benefits and challenges of telehealth; however, little is known about the impacts of telehealth on the quality, use, and effectiveness of treatment. Fewer studies examine how these emerging digital geographies of care transform the spaces and landscapes of substance misuse. This article examines how telehealth affects landscapes of opioid use disorder care in Pennsylvania, West Virginia, and Kentucky during the COVID-19 pandemic. Our findings reveal that while telehealth extends access to treatment for opioid use disorder (OUD), it also creates new care inequities within and between providers and clientele that can undermine effective care and recovery.

Landscapes of inequities, structural racism, and disease during the COVID-19 pandemic: Experiences of immigrant and racialized populations in Canada.

The COVID-19 pandemic has disproportionately affected immigrant and racialized communities globally and revealed another public health crisis - structural racism. While structural racism is known to foster discrimination via mutually reinforcing systems, the unevenness of COVID-19 infections, hospitalizations, and deaths across societies has precipitated attention to the impacts of structural racism. Research highlights the inequitable burden of COVID-19 among immigrant and racialized groups; however, little is known about the synergistic impacts of structural racism and COVID-19 on the health and wellbeing of these groups. Fewer studies examine how structural racism and COVID-19 intersect within neighbourhoods to co-produce landscapes of disease exposure and management. This article examines the pathways through which structural racism shapes access, use, and control of environmental resources among immigrant and racialized individuals in the neighbourhoods of the Peel Region and how they converged to shape health and disease dynamics during the height of Canada's COVID-19 pandemic. Findings from in-depth interviews reveal that mutually reinforcing inequitable systems created environments for COVID-19 to reinscribe disparities in access, use, and control of key resources needed to manage health and disease, and created new forms of disparities and landscapes of inequality for immigrants and racialized individuals. We close with a discussion on the impacts for policy and practice.

Access to emergency care in Egypt: Tiered health care and manifestations of inequity.

Market-driven health care reforms and development strategies continue to drive the privatization of health care services across the world. When these measures are implemented, large disparities emerge and are maintained. Using a modified version of the access to care framework developed by Penchansky and Thomas, this paper examines the manifestations of inequity between private for-profit and public emergency care in the Greater Cairo Region and Asyut, Egypt. In-depth interviews with physicians working in both sectors reveals stark disparities in access between these two health care sectors in Egypt. Access issues identified include unaffordable care in the private sector, unavailable medical supplies and overcrowding in public hospitals, as well as a salary gap that drives health care workers from public to private practice, creating staffing shortages in public hospitals. The manifestations of these inequities are often severe, usually tangible, and according to health care providers, embodied in the experiences of service users.

Lived Experiences of the COVID-19 Pandemic Among the Vietnamese Population in the Region of Peel.

Racial discrimination towards Southeast Asian populations is a longstanding issue in Canada which has intensified during the COVID-19 pandemic. Although extensive work demonstrates inequities among Southeast Asian communities during the pandemic, much work categorizes Asians as one homogenous population neglecting the unique experiences of different Asian subgroups along with the ways COVID-19 differentially affects Southeast Asians. To attend to population variations, this paper explores the lived experiences among Vietnamese individuals during the pandemic in the Peel Region of Ontario Canada. Specifically, this paper examines social and economic impacts of COVID-19, access to healthcare services and vaccines, sources of vaccine information, and impacts of COVID-19 related discrimination among young and older adults. Drawing on in-depth interviews with young and older adults (n=6:8) the results reveal important social and economic impacts created by COVID-19 that vary across generations and impact health and wellbeing. These impacts are challenged further by barriers to healthcare access which were compounded by intersecting inequities experienced among Vietnamese immigrants in the Peel Region. While vaccine hesitancy was not a main concern, the findings demonstrate important generational differences with respect to commonly used and trusted information related to historical events and social media use. Although racial discrimination was a dominant concern, younger participants did not feel unsafe but expressed concern for the safety of their older family members and friends. The study underscores the need to consider historical dynamics and the ways they shape government opinions and trust, experiences of racial discrimination and socio-economic realities among racialized, immigrant populations.

Navigating the quality-of-life impacts of a chronic inflammatory disease (CID) among South Asian children and parents.

This study investigates quality-of-life impacts (QOL) associated with managing a chronic inflammatory disease (CID) among first and second generation South Asian children and parents in the Greater Toronto Area, Ontario. While empirical evidence on both the rise of CIDs among immigrants and the QOL impacts of managing a CID is increasing, little attention has been given to the QOL impacts of managing a CID among immigrant adult children and their families. Drawing on analysis of 24 in-depth interviews with adult children and parents (14 adult children, 10 parents) the results indicate that first and second generation South Asian adult children and parents experience challenges acquiring a CID diagnosis (e.g., bureaucratic issues, transportation, inconsistent and unavailable physician care), and encounter multidimensional short- and long-term QOL implications associated with CID management. These challenges are compounded further by culturally insensitive care and language barriers in the health system. QOL impacts associated with CID management among adult children ranged from comfort and peace of mind due to increased ability to participate in daily life, while others reported intensified anxiety, stress and depression due to their inability to fully engage in daily life. Although all parents reported heightened stress due to their child's CID diagnosis and new management regimens, parents employed different coping mechanisms that created new short term QOL challenges for their families. The findings suggest that a patient centered approach to CID diagnosis and management, informed by personal experiences, cultural sensitivities and lived experiences of QOL representations are needed to mitigate negative QOL outcomes across a patient's life and deliver appropriate evidence informed care for those in need.

Geographic variations in opioid overdose patterns in Pennsylvania during the COVID-19 pandemic.

The convergence of the opioid epidemic and the COVID-19 pandemic has created new health challenges throughout the United States. Since the onset of the pandemic, media attention and scholarly research have drawn attention to the intersections of addiction and COVID-19. However, there remain few empirical studies that examine the direct impacts of the COVID-19 pandemic for opioid overdose patterns. Even fewer have integrated quantitative and qualitative methods to detail the place-specific dynamics shaping opioid overdose and addiction treatment during the COVID-19 pandemic. This article measures and maps change in the age-adjusted rate of opioid-related overdose incidents at the county level from 2018 to 2020. These analyses are combined with interviews conducted since December 2020 with public health providers in the state of Pennsylvania to identify the key factors influencing opioid misuse and transformations in addiction treatment practices.

Health Care Use and Barriers to Care for Chronic Inflammatory Diseases (CID) among First and Second Generation South Asian Immigrant Children and Parents in Ontario Canada.

Although immigrants are disproportionately impacted by growing chronic inflammatory disease (CIDs) rates, yet suffer barriers to access health care, little attention has been given to their primary healthcare or specialist healthcare access as it relates to complex, chronic diseases in Canada, a country with universal health care. This study aims to investigate CID health care use and barriers to care among first- and second-generation immigrant South Asian children and parents in the Greater Toronto Area, Ontario. Drawing on analysis of 24 in depth interviews with children and parents (14 children, 10 parents), the results reveal that although CIDs disproportionately affects South Asian immigrants, they encounter health system, geographic, interpersonal, and knowledge barriers to access requisite care. These barriers exist despite participants having a GP, and are compounded further by limited familial systems, culturally insensitive care, and structural inequities that in some instances make parents choose between health access or other basic needs. Although all participants recognized the importance of specialized care, only 11 participants regularly accessed specialized care, creating new schisms in CID management. The findings suggest that a multisectoral approach that address individual and structural level socio-structural drivers of health inequities are needed to create more equitable healthcare access.

Disparities in opioid overdose survival and naloxone administration in Pennsylvania.

BACKGROUND: Pennsylvania has one of the highest opioid overdose rates in the US; however, since 2018 approximately 80% of people who experienced an opioid overdose in the state survived. More attention has been paid to opioid overdose mortality despite notable individual and geographic differences in overdose survival. Naloxone is an essential tool in increasing chances of survival after opioid overdose, but its availability and the rate at which it is administered differs by county in Pennsylvania and nationally. METHODS: We use 2018-2020 Pennsylvania Overdose Information Network data on opioid incidents and where they occurred, combined with 2015-2019 American Community Survey data, to evaluate opioid overdose survival and naloxone administration by county over a three-year period. RESULTS: Individuals who received at least one dose of naloxone following overdose had 11 times greater odds of survival. White, middle-aged men were least likely to survive opioid overdose. Both survival and naloxone administration rates differed by county with lower rates in less populated counties. CONCLUSION: Expanding naloxone distribution and administration and ensuring proper education about standing orders for naloxone administration are important tools for addressing opioid overdose mortality.

Getting Old Well in Sub Saharan Africa: Exploring the Social and Structural Drivers of Subjective Wellbeing among Elderly Men and Women in Uganda.

While literature attempts to explain why self-reported subjective wellbeing (SWB) generally increases with age in most high-income countries based on a social determinants of a health framework, little work attempts to explain the low levels of self-report SWB among older persons in sub-Saharan Africa. Using the 2013 Uganda Study on Global Aging and Health with 470 individuals, this research examines (i) direct and indirect effects of age on SWB through social and structural determinants, and (ii) how direct and indirect effects vary by gender. Results show a significant direct and negative effect of age on SWB (ß = 0.42, p = 0.01). Six indirect paths were statistically significant and their indirect effects on wellbeing varied by gender. Providing support, education, working status, asset level, financial status and financial improvement were significantly positively associated with men's SWB, whereas younger age, providing community support, participating in group activities, number of close friends/relatives, government assistance and all socio-economic variables were significantly positively associated with women's SWB. Strategies to address gendered economic, social and political inequalities among and between elderly populations are urgently needed.

Men's perceptions of women's reproductive health in South Sudan.

This paper draws on a qualitative study (n = 52) and applies a political ecology of health framework to examine men's perceptions of women's reproductive health in South Sudan. The findings suggest that political practices of place making configure men's views of women's reproductive roles in this new nation state. In particular, masculinity intertwines with fears of losing traditional culture, and with lingering concerns about sovereignty to underpin men's deep aversion to modern family planning methods. In addition, the use of tribal militia to control territory and leverage political power places women's reproduction at the centre of South Sudan's post-secession politics. Improving health in such a fragile environment may require more than rebuilding the health infrastructure and guaranteeing financial access to health care.

Global environmental change in an aging world: The role of space, place and scale.

'Space' and 'aging in place' are central concepts in the geography of aging. Yet little geographic work compares aging across or within places globally, with a virtual disregard to aging in low and middle income countries. With aging now an axiomatic backdrop for research and policy on 21st century populations, this paper explores how space and place are used in theory and practice within the geography of aging. Drawing from literature within the discipline, this paper discusses how space and place are often theorized as dichotomies - conceptualized as macro space and micro place. This results in the neglect of multiscalar processes that shape aging dynamics globally. While the geographies of aging have become a substantive discipline within human geography writ large, the full repertoire of geographical concepts has yet to be applied within the sub discipline. In order for the discipline to reflect current and emerging global aging dynamics, the paper advocates how and why engagement with scale is needed on two interrelated fronts. First, we propose the need to scale out, illuminating the diversity of aging in global regions undergoing profoundly diverse demographic transitions. Second, we propose the need to scale up, connecting processes across micro place and macro space, bearing in mind all global regions. Engaging questions of scale would elucidate how 'aging in place' is informed by multiple relational dynamics, operating across innumerable scales worldwide. This would reposition 'aging in place' as a fluid process shaped by factors across scales. Drawing fully on geography's conceptual repertoire would immeasurably strengthen sub-disciplinary substantive knowledge, theoretical knowledge, and policy relevance. The paper concludes with a discussion of these shifts in scale for aging research, emphasizing the need for geographic (aging and health sub disciplines) and related social science research.

"It's Like a Disease": Women's perceptions of caesarean sections in Ghana's Upper West Region.

PROBLEM: While caesarean sections in developing contexts act as a marker for access to skilled care, little is known about the health outcomes of caesarean sections. With calls for a more in depth understanding of women's perceptions of this procedure in resource poor settings, this paper explores women's perceptions and experiences of caesarean birth in the context of Ghana's Maternal Exemption Policy of the National Health Insurance Scheme in the Upper West Region. METHODS: A qualitative study using 10 focus group discussions and 30 in depth interviews of mothers and pregnant women were conducted. The results were thematically analysed. FINDINGS: Drawing on theories of feminist geography and embodiment, the results suggest most women perceive caesarean section birth as highly problematic, acting as a long term disease, which hinders their ability to engage in economic activities and care for their children. In the context of the Maternal Exemption Policy, caesarean section birth restricts a woman's ability to secure further health insurance for themselves and newborn child, leaving long term access to health care uncertain. Findings also suggest long term repercussions of caesarean sections may go beyond the physical health of the mother and child to include other socio-cultural and contextual challenges. DISCUSSION: Accordingly, caesarean sections position women in a multifaceted situation of vulnerability. This underscores the need for context appropriate maternal health programmes in developing countries.

"I was on the way to the hospital but delivered in the bush": Maternal health in Ghana's Upper West Region in the context of a traditional birth attendants' ban.

This study examines perceptions and experiences of mothers, traditional birth attendants (TBA), and skilled birth attendants (SBA) regarding Ghana's recent policy that forbids TBAs from undertaking deliveries and restricts their role to referrals. In the larger context of Ghana's highly underdeveloped and geographically uneven health care system, this study draws on the political ecology of health framework to explore the ways global safe motherhood policy discourses intersect with local socio-cultural and political environments of Ghana's Upper West Region (UWR). This study reveals that futile improvements in maternal health and the continued reliance on TBAs illustrate the government's inability to understand local realities marked by poor access to SBAs or modern health care services. Using focus group discussions (FGDs) (n = 10) and in-depth interviews (IDIs) (n = 48) conducted in Ghana's UWR, the findings suggest that mothers generally perceive TBAs as better placed to conduct deliveries in rural isolated communities, where in most cases no SBAs are present or easily accessible. The results indicate that by adhering to the World Health Organization's guidelines, the local government may be imposing detrimental, unintended consequences on maternal and child health in remote rural locations. In addition, the findings suggest that the new policy has resulted in considerable confusion among TBAs, many of whom remain oblivious or have not been officially notified about the new policy. Furthermore, participant accounts suggest that the new policy is seen as contributing to worsening relations and tensions between TBAs and SBAs, a situation that undermines the delivery of maternal health services in the region. The study concludes by suggesting relevant policy recommendations.

Can she make it? Transportation barriers to accessing maternal and child health care services in rural Ghana.

BACKGROUND: The Ghana Community based Health Planning and Services (CHPS) strategy targets to bring health services to the doorsteps of clients in a manner that improves maternal and child health outcomes. In this strategy, referral is an important component but it is threatened in a rural context where transportation service is a problem. Few studies have examined perceptions of rural dwellers on transportation challenges in accessing maternal health care services within CHPS. METHODS: Using the political ecology of health framework, this paper investigates transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system. Eight (8) focus group discussions involving males (n = 40) and females (n = 45) in rural communities in a CHPS zone in the Upper West Region of Ghana were conducted between September and December 2013. RESULTS: Lack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services. CONCLUSION: These findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.