Scaling up the "24/7 BHU" strategy to provide round-the-clock maternity care in Punjab, Pakistan: a theory-driven, coproduced implementation study.

BACKGROUND: Pakistan's maternal mortality rate remains persistently high at 186/100,000 live births. The country's government-run first-level healthcare facilities, the basic health units (BHUs), are an important source of maternity care for rural women. However,BHUsonly operate on working days from 8:00 am to 2:00 pm. Recognizing that this severely constrains access to maternity services, the government is implementing the "24/7 BHU" initiative to upgrade BHUs to provide round-the-clock care. Although based on a successful pilot project, initial reports reveal challenges in scaling up the initiative. This implementation research project aims to address a key concern of the Government of Punjab: How can the 24/7 BHU initiative be successfully implemented at scale to provide high-quality, round-the-clock skilled maternity care in rural Punjab? METHODS: The project consists of two overlapping work packages (WP). WP1 includes three modules generating data at the directorate, district and BHU levels. Module 1 uses document analysis and policy-maker interviews to explicateprogrammetheory and begin to build a system model. Module 2 compares government-collected data with data generated from a survey of 1500 births to assess BHU performance. Module 3 uses institutional ethnographies in 4-5 BHUs in three districts to provide a detailed system for understanding and identifying processes that influence scale-up. WP2 includes two modules. First, two workshops and regular meetings with stakeholders integrate WP1 findings, identify feasible changes and establish priorities. Next, "change ideas" are selected for testing in one district and 2-3 BHUs through carefully documented pilots using the PDSA (plan-do-study-act) improvement approach. An integrated knowledge translation approach will engage key policy and practice stakeholders throughout the project. DISCUSSION: This theory-driven implementation research project willcoproducesignificant new understandings of the wider system in which the 24/7 BHU initiative is being implemented, and actionable knowledge that will highlight ways the implementation processes might be modified to enable BHUs to meet service provision goals. This study will also produce insights that will be relevant for other South Asian and low- and middle-income countries (LMICs) that experience similar challenges of programme scale-up and delivery of maternal health services to remote and marginalized communities.

Neighbourhood deprivation and intersectional inequalities in biomarkers of healthy ageing in England.

While social and spatial determinants of biomarkers have been reported, no previous study has examined both together within an intersectional perspective. We present a novel extension of quantitative intersectional analyses using cross-classified multilevel models to explore how intersectional positions and neighbourhood deprivation are associated with biomarkers, using baseline UK Biobank data (collected from 2006 to 2010). Our results suggest intersectional inequalities in biomarkers of healthy ageing are mostly established by age 40-49, but different intersections show different relationships with deprivation. Our study suggests that certain biosocial pathways are more strongly implicated in how neighbourhoods and intersectional positions affect healthy ageing than others.

Researching the health and social inequalities experienced by European Roma populations: Complicity, oppression and resistance.

This paper draws on the experience of two Romani and three non-Romani scholars in knowledge production on the health and social inequalities experienced by European Roma populations. Together, we explore how we might better account for, and work against, the complex web of dynamic oppressions embedded within processes of academic knowledge production. Our aim is to encourage careful scrutiny through which sociologists of health and illness might better recognise our own complicity with oppression and identify concrete actions towards transforming our research practices. Drawing on a well-known domains of racism typology (Annual Review of Public Health, 40, 2019, 105), we use examples from our own work to illustrate three interconnected domains of oppression in which we have found ourselves entangled (structural, cultural and interpersonal). A new conceptual framework is proposed as an aid to understanding the spectrum of different "types" of complicity (voluntary-involuntary, conscious-unconscious) that one might reproduce across all three domains. We conclude by exploring how sociologists of health and illness might promote a more actively anti-racist research agenda, identifying and challenging subtle, hidden and embedded negative ideologies and practices as well as more obviously oppressive ones. We hope these reflections will help revitalise important conversations.

Can intersectionality help with understanding and tackling health inequalities? Perspectives of professional stakeholders.

BACKGROUND: The concept of "intersectionality" is increasingly employed within public health arenas, particularly in North America, and is often heralded as offering great potential to advance health inequalities research and action. Given persistently poor progress towards tackling health inequalities, and recent calls to reframe this agenda in the United Kingdom and Europe, the possible contribution of intersectionality deserves attention. Yet, no existing research has examined professional stakeholder understandings and perspectives on applying intersectionality to this field. METHODS: In this paper we seek to address that gap, drawing upon a consultation survey and face-to-face workshop (n = 23) undertaken in the United Kingdom. The survey included both researchers (n = 53) and policy and practice professionals (n = 20) with varied roles and levels of engagement in research and evaluation. Topics included familiarity with the term and concept "intersectionality", relevance to health inequalities work, and issues shaping its uptake. Respondents were also asked to comment on two specific policy suggestions: intersectionally targeting and tailoring interventions, and evaluating the intersectional effects of policies. The workshop aims were to share examples of applying intersectionality within health inequalities research and practice; understand the views of research and practice colleagues on potential contributions and challenges; and identify potential ways to promote intersectional approaches. RESULTS: Findings indicated a generally positive response to the concept and a cautiously optimistic assessment that intersectional approaches could be valuable. However, opinions were mixed and various challenges were raised, especially around whether intersectionality research is necessarily critical and transformative and, accordingly, how it should be operationalized methodologically. Nonetheless, there was general agreement that intersectionality is concerned with diverse inequalities and the systems of power that shape them. CONCLUSIONS: We position intersectionality within the wider context of health inequalities policy and practice, suggesting potential ways forward for the approach in the context of the United Kingdom. The views of policy and practice professionals suggest that intersectionality has far to travel to help counter individualistic narratives and to encourage an approach that is sensitive to subgroup inequalities and the processes that generate them. Examples of promising practice, albeit mostly in North America, suggest that it is possible for intersectionality to gain traction.

Transnational social networks, health, and care: a systematic narrative literature review.

While transnational social ties and exchanges are a core concern within migration studies, health researchers have often overlooked their importance. Continuous and circular exchanges of information within transnational networks, also defined as social remittances, facilitate the diffusion of innovations, potentially driving contemporary social and cultural change. Influences on health, wellbeing, and care-seeking are important, but under-researched, dimensions for consideration. We undertook a systematic narrative evidence synthesis to describe the current state of knowledge in this area and to identify gaps and future directions for health researchers to take. Between April 2017 and May 2019, an iterative series of searches in Medline, Embase, PsycINFO and PubMed, plus backward and forward citation searches identified 1173 potential papers. Screening resulted in 36 included papers, eighteen focused on migrant populations and eighteen on those who remain behind. The top three health topics were health-seeking strategies, sexual and reproductive health issues, and healthcare support. And, while not always explicitly identified, mental health and wellbeing was a further prominent, cross-cutting theme. Articles on migrant populations were all conducted in the global North and 13 out of 18 used qualitative methods. Five main themes were identified: therapeutic effect of the continuing social relationships, disrupted social relationships, hybridisation of healthcare, facilitation of connections to healthcare providers, and factors encouraging or undermining transnational social exchanges. Papers concerned with those who remain behind were mainly focused on the global South and used a mix of qualitative and quantitative approaches. Four main themes were identified: transnational transfer of health-related advice, norms, and support; associations between migrant linkages and health behaviours/outcomes; transnational collective transfer of health knowledge; and power and resistance in exchanges. Findings suggest that transnational social exchanges can both support and undermine the health of migrants and those who remain behind. This review confirms that the volume and quality of research in this area must be increased so that health policy and practice can be informed by a better understanding of these important influences on the health of both migrants and those who remain behind.

Power, control, communities and health inequalities. Part II: measuring shifts in power.

In the health field, there is great interest in the role empowerment might play in reducing social inequalities in health. Empowerment is understood here as the processes of developing capabilities that individuals and/or communities need to exercise control over decisions and actions impacting on their lives and health. There is a fundamental problem, however, in identifying and measuring capabilities for collective control that emerge at the level of the collective, with much of the existing literature focusing on individual measures even where community-level processes are concerned. Collective measures need to capture the dynamics of interactions within and between groups, not simply aggregate individual-level measures. This article, Part 2 in a three-part series, takes up the challenge of identifying qualitative markers of capabilities for collective control. We applied the emancipatory power framework (EPF) reported in Part 1 of the series, to qualitative data generated during a longitudinal evaluation of a major English area-based empowerment initiative, the Big Local (BL). We identified empirical 'markers' of shifts towards greater collective control pertaining to each of the 'power' dimensions in the EPF-'power within', 'power with' and 'power to'-and markers of communities exercising 'power over' other institutions/community members. These markers can usefully be applied in the evaluation planning and evaluation of empowerment initiatives. Part 3 in the series uses these markers and a second analytical framework developed during our evaluation of BL to explore how power dynamics unfold in participatory spaces in BL neighbourhoods.

Power, control, communities and health inequalities III: participatory spaces-an English case.

This article-third in a series of three-uses theoretical frameworks described in Part 1, and empirical markers reported in Part 2, to present evidence on how power dynamics shifted during the early years of a major English community empowerment initiative. We demonstrate how the capabilities disadvantaged communities require to exercise collective control over decisions/actions impacting on their lives and health (conceptualized as emancipatory power) and the exercise of power over these communities (conceptualized as limiting power) were shaped by the characteristics of participatory spaces created by and/or associated with this initiative. Two main types of participatory spaces were identified: governance and sense-making. Though all forms of emancipatory power emerged in all spaces, some were more evident in particular spaces. In governance spaces, the development and enactment of 'power to' emerged as residents made formal decisions on action, allocated resources and managed accountability. Capabilities for alliance building-power with-were more likely to emerge in these spaces, as was residents' resistance to the exercise of institutional power over them. In contrast, in sense-making spaces residents met informally and 'made sense' of local issues and their ability to influence these. These processes led to the development of power within capabilities and power to resist stigmatizing forms of productive power. The findings highlight the importance of designing community initiatives that: nurture diverse participatory spaces; attend to connectivity between spaces; and identify and act on existing power dynamics undermining capabilities for collective control in disadvantaged communities.

Mapping intersectional inequalities in biomarkers of healthy ageing and chronic disease in older English adults.

Chronic diseases and their inequalities amongst older adults are a significant public health challenge. Prevention and treatment of chronic diseases will benefit from insight into which population groups show greatest risk. Biomarkers are indicators of the biological mechanisms underlying health and disease. We analysed disparities in a common set of biomarkers at the population level using English national data (n = 16,437). Blood-based biomarkers were HbA1c, total cholesterol and C-reactive protein. Non-blood biomarkers were systolic blood pressure, resting heart rate and body mass index. We employed an intersectionality perspective which is concerned with how socioeconomic, gender and ethnic disparities combine to lead to varied health outcomes. We find granular intersectional disparities, which vary by biomarker, with total cholesterol and HbA1c showing the greatest intersectional variation. These disparities were additive rather than multiplicative. Each intersectional subgroup has its own profile of biomarkers. Whilst the majority of variation in biomarkers is at the individual rather than intersectional level (i.e. intersections exhibit high heterogeneity), the average differences are potentially associated with important clinical outcomes. An intersectional perspective helps to shed light on how socio-demographic factors combine to result in differential risk for disease or potential for healthy ageing.

Modern slavery in the UK: how should the health sector be responding?

Modern slavery is crime of extreme exploitation. It includes the use of coercion, force, deception and abuse of vulnerability for such purposes as trafficking, labour, sexual exploitation, forced criminal activity and domestic servitude. It is a topic of growing interest in the UK and beyond as it has emerged as an issue of considerable scale and consequence. To date, debates have been dominated by a law enforcement perspective. Less apparent has been an articulation of the implications of modern slavery for the health sector. This is despite growing evidence of the dire physical and mental health consequences for survivors. This paper addresses this gap by examining a series of issues relevant to UK health systems. After describing what is modern slavery and the nature of the problem, we identify how the health sector has responded to date. We then articulate how health services and public health can more coherently and systematically meet the challenges of modern slavery through policy and practice. Finally, we present a call for the health sector to position itself as a central to the wellbeing of survivors and as a fundamental ally in modern slavery prevention.

Challenges to achieving appropriate and equitable access to Caesarean section: ethnographic insights from rural Pakistan.

Access to Caesarean section (C-section) remains inadequate for some groups of women while others have worryingly high rates. Understanding differential receipt demands exploration of the socio-cultural, and political economic, characteristics of the health systems that produce them. This extensive institutional ethnography investigated under- and over-receipt of C-section in two rural districts in Pakistan - Jhelum and Layyah. Data were collected between November and July 2013 using semi-structured interviews from a randomly selected sample of 11 physicians, 38 community midwives, 18 Lady Health Visitors and nurses and 15 Traditional Birth Attendants. In addition, 78 mothers, 35 husbands and 23 older women were interviewed. The understandings of birth by C-section held by women and their family members were heavily shaped by gendered constructions of womanhood, patient-provider power differentials and financial constraints. They considered C-section an expensive and risky procedure, which often lacked medical justification, and was instead driven by profit motive. Physicians saw C-section as symbolizing obstetric skill and status and a source of legitimate income. Physician views and practices were also shaped by the wider health care system characterized by private practice, competition between providers and a lack of regulation and supervision. These multi-layered factors have resulted in both unnecessary intervention, and missed opportunities for appropriate C-sections. The data indicate a need for synergistic action at patient, provider and system levels. Recommendations include: improving physician communication with patients and family so that the need for C-section is better understood as a life-saving procedure, challenging negative attitudes and promoting informed decision-making by mothers and their families, holding physicians accountable for their practice and introducing price caps and regulations to limit financial incentives associated with C-sections. The current push for privatization of health care in low-income countries also needs scrutiny given its potential to encourage unnecessary intervention.

How should health policy and practice respond to the increased genetic risk associated with close relative marriage? results of a UK Delphi consensus building exercise.

OBJECTIVES: (1) To explore professional and lay stakeholder views on the design and delivery of services in the area of consanguinity and genetic risk. (2) To identify principles on which there is sufficient consensus to warrant inclusion in a national guidance document. (3) To highlight differences of opinion that necessitate dialogue. (4) To identify areas where further research or development work is needed to inform practical service approaches. DESIGN: Delphi exercise. Three rounds and one consensus conference. SETTING: UK, national, web-based and face-to-face. PARTICIPANTS: Recruitment via email distribution lists and professional networks. 42 participants with varied professional and demographic backgrounds contributed to at least one round of the exercise. 29 people participated in statement ranking across both rounds 2 and 3. RESULTS: Over 700 individual statements were generated in round 1 and consolidated into 193 unique statements for ranking in round 2, with 60% achieving 80% or higher agreement. In round 3, 74% of statements achieved 80% or higher agreement. Consensus conference discussions resulted in a final set of 148 agreed statements, providing direction for both policy-makers and healthcare professionals. 13 general principles were agreed, with over 90% agreement on 12 of these. Remaining statements were organised into nine themes: national level leadership and coordination, local level leadership and coordination, training and competencies for healthcare and other professionals, genetic services, genetic literacy, primary care, referrals and coordination, monitoring and evaluation and research. Next steps and working groups were also identified. CONCLUSIONS: There is high agreement among UK stakeholders on the general principles that should shape policy and practice responses in this area: equity of access, cultural competence, coordinated inter-agency working, co-design and empowerment and embedded evaluation. The need for strong national leadership to ensure more efficient sharing of knowledge and promotion of more equitable and consistent responses across the country is emphasised.

Enhancing health literacy through co-design: development of culturally appropriate materials on genetic risk and customary consanguineous marriage.

AimTo develop a simple health literacy intervention aimed at supporting informed reproductive choice among members of UK communities practising customary consanguineous marriage. BACKGROUND: The contribution of 'health literacy' to reducing health inequalities and improving primary health-care efficiency is increasingly recognised. Enhancing genetic literacy has received particular attention recently. Consanguineous marriage is customarily practised among some UK minority ethnic communities and carries some increased risk of recessive genetic disorders among offspring compared with unions among unrelated partners. The need to enhance genetic literacy on this issue has been highlighted, but no national response has ensued. Instead, a range of undocumented local responses are emerging. Important knowledge gaps remain regarding how the development and implementation of culturally appropriate, effective and sustainable responses can be achieved. METHODS: Our co-design approach involved active participation by local people. Initial insight generation employed six focus group discussions and 14 individual interviews to describe current understandings and information needs. A total of 11 personas (heuristic narrative portraits of community 'segments') resulted; four participatory workshops provided further understanding of: preferred information channels; feasible information conveyance; and responses to existing materials. Prototype information resources were then developed and feedback gathered via two workshops. Following further refinement, final feedback from health-care professionals and community members ensured accuracy and appropriateness.FindingsThe project demonstrated the utility of co-design for addressing an issue often considered complex and sensitive. With careful planning and orchestration, active participation by diverse community members was achieved. Key learning included: the importance of establishing trusting and respectful relationships; responding to diversity within the community; and engendering a creative and enjoyable experience. The resultant materials were heavily shaped by local involvement. Evaluative work is now needed to assess impacts on knowledge and service uptake. Longer term sustainability will depend on whether innovative community-level work is accompanied by broader strategy including investment in services and professional development.

Roma populations and health inequalities: a new perspective.

PURPOSE: The purpose of this paper is to explore the emergence of "Roma health and wellbeing" as a focus of attention in European research and in policy and the possible detrimental consequences of action founded on a generic representation of "Roma health." DESIGN/METHODOLOGY/APPROACH: Based on discussions with and research conducted by scholars who work directly with Roma communities across European regions from a wide range of academic disciplines it suggests how future research might inform: a more nuanced understanding of the causes of poor health and wellbeing among diverse Roma populations and; actions that may have greater potential to improve the health and wellbeing among these populations. FINDINGS: In summary, the authors promote three types of research: first critical analyses that unpick the implications of current and past representations of "Roma" and "Roma health." Second, applied participatory research that meaningfully involves people from specific self-defined Roma populations to identify important issues for their health and wellbeing. Third, learning about processes that might impact on the health and wellbeing of Roma populations from research with other populations in similarly excluded situations. ORIGINALITY/VALUE: The authors provide a multidisciplinary perspective to inform research that does not perpetuate further alienation and prejudice, but promotes urgent action to redress the social and health injustices experienced by diverse Roma populations across Europe.

Frontal alpha asymmetry in alcohol-related intimate partner violence.

Electroencephalographic (EEG) frontal alpha asymmetry (FAA) has been associated with differences in the experience and expression of emotion, motivation and anger in normal and clinical populations. The current study is the first to investigate FAA in alcohol-related intimate partner violence. EEG was recorded from 23 distressed violent (DV) and 15 distressed nonviolent (DNV) partners during a placebo-controlled alcohol administration and emotion-regulation study. The State-Trait Anger Expression Inventory 2 was used to evaluate anger experiences and was collected from both participants and their partners. During baseline, acute alcohol intoxication DV partners had significantly greater right FAA, whereas DNV partners showed greater left FAA. Both partner types demonstrated significantly greater right FAA during the placebo beverage condition of the emotion-regulation task when viewing evocative partner displays of contempt, belligerence, criticism, defensiveness and stonewalling, but greater left FAA during acute alcohol intoxication. Although no group differences were found in the emotion-regulation task, partner self-reported anger experiences accounted for 67% of the variance in the FAA of DV participants when intoxicated and viewing evocative stimuli, suggesting dyadic processes are important in understanding alcohol-related IPV. These findings suggest that FAA could index the affective and motivational determinants through which alcohol is related to IPV.

Reframing "participation" and "inclusion" in public health policy and practice to address health inequalities: Evidence from a major resident-led neighbourhood improvement initiative.

There is a need for greater conceptual clarity in place-based initiatives that seek to give residents of disadvantaged neighbourhoods more control over action to address the social determinants of health inequalities at a local level. In this article, we address this issue as it relates to the concepts of participation and inclusion. We draw on qualitative data generated during the first phase of the Communities in Control Study, a longitudinal multisite independent evaluation of the impact of Big Local on the social determinants of health and health inequalities. Big Local is a resident-led area improvement initiative in England, funded by the UK Big Lottery Fund. Initiatives focused on community empowerment are increasingly prominent in public health policy and practice globally. Approaches emphasise the promotion of greater control over decisions and action among individuals, groups, and communities, particularly those living in disadvantaged circumstances. However, when it comes to participation and inclusion in taking action and making decisions, the field is characterised by conceptual confusion. This risks undermining the impact of these initiatives. While participation and inclusion are necessary conditions for empowerment and collective control, they are not necessarily sufficient. Sufficiency requires attention to the breadth of participation (i.e., to inclusion) and to the depth of participation (i.e., the extent to which it is experienced as empowering and ultimately enables the exercise of collective control over decisions and actions). In observing how different Big Local resident-led partnerships across England are tackling the day-to-day challenges of engaging with their communities, we reveal the potential for policy and practice of reframing, and therefore clarifying (to highlight the different roles they have) the concepts of participation and inclusion in terms of depth and breadth.

Adjusting a mainstream weight management intervention for people with intellectual disabilities: a user centred approach.

BACKGROUND: People with intellectual disabilities (ID) may not be able to access and respond to uniformly delivered health interventions. Public bodies have a legal duty to make 'reasonable adjustments' to policies and practices to provide fair access and treatment for people with ID. This study aimed to identify adjustments to the Slimming World weight management programme to improve accessibility and assess acceptability and feasibility for this population. METHODS: This user-centred qualitative study was carried out with a steering group of people with ID (n = 4). Barriers and facilitators to using Slimming World were identified through interviews and focus groups with people with ID (n = 54), carers (n = 12) current members with ID (n = 8) and Slimming World group leaders (n = 11). Adjustments were made and their feasibility and acceptability were explored in a before-and-after mixed methods study where people with ID attended Slimming World for eight weeks. Participants (n = 9), carers (n = 7) and Slimming World group leaders (n = 4) were interviewed to explore their experiences of the adjustments. Participants were weighed at baseline then each week. RESULTS: Four key adjustments were identified and addressed by Slimming World who developed prototype Easy Read materials and a letter for carers. Six of the nine participants attended Slimming World for eight weeks and lost weight (1.4 kg to 6.6 kg, reduction in BMI between 0.5 and 1.7 kg/m2), indicating that the adjustments were feasible and acceptable. Two participants dropped out because they felt uncomfortable in a mainstream group and another left because they lacked control over food choice in their residential setting. CONCLUSIONS: This user-centred approach identified reasonable adjustments that were feasible to implement. In a small uncontrolled feasibility study, people with ID were positive about the adjustments and lost weight. However, issues in the wider context of people's lives, such as obesogenic environments and concerns about joining mainstream groups, limited the acceptability of Slimming World even with these adjustments. These findings have important implications for policy and suggest that environmental and organisational level interventions are needed alongside those targeting individual behaviour to tackle the obesogenic environment in which many people with ID spend their time, in order to reduce inequalities associated with the consequences of obesity.