Crowdfunding narratives and the valuation of vaccines for COVID-19.

Social media spreads information about vaccines and can be used to better understand public attitudes about them. Using American crowdfunding campaigns that mentioned COVID-19 vaccines from January 2020 to March 2021, this paper investigates public attitudes towards vaccines, specifically the perceived role vaccines could (or couldn't) play in ending the pandemic. We identified 776 crowdfunding campaigns and coded each for their aims and whether they valued vaccines as returning their community to a pre-pandemic state (utopian), helping some but not all people (cautious), and doubtful about the likely positive impacts of vaccines (skeptical). Cautious and skeptical valuations increased over time whereas utopian views declined. This paper uniquely situates attitudes toward COVID-19 vaccines in the context of financial need (as characterized by the campaigners). It offers insight into the "vaccine class gap" in America and demonstrates the usefulness of crowdfunding campaigns for assessing public views on vaccines.

Spatial and temporal patterns in Canadian COVID-19 crowdfunding campaigns.

Online charitable crowdfunding has become an increasingly prevalent way for Canadians to deal with costs that they would otherwise not be able to shoulder on their own. With the onset of COVID-19 and related lockdown measures, there is evidence of a surge in crowdfunding use relating to the pandemic. This study gathered, classified, and analysed Canadian crowdfunding campaigns created in response to COVID-19 from GoFundMe.com, a popular crowdfunding platform. Spatio-temporal analysis of classified campaigns allowed for observation of emergent trends in the distribution of pandemic-related need incidence and financial support throughout the pandemic. Campaigns raising money on behalf of established charities were the most common in the sample, and accounted for the greatest portion of funding raised, while campaigns for businesses made up a small proportion. Dense metropolitan areas accounted for the vast majority of campaign locations, and total sample funding was disproportionately raised by campaigners in Ontario and British Columbia.

What was lost, missing, sought and hoped for: Qualitatively exploring medical crowdfunding campaign narratives for Lyme disease.

Lyme disease remains a contested illness in Canada, thereby making the diagnostic and treatment journeys difficult for some people. One outcome of this is that increasing numbers of people are turning to medical crowdfunding to support access to alternative therapies, non-local health care providers and assist with managing the costs of everyday life. In this analysis, we qualitatively explore the narratives shared in Canadians' crowdfunding campaigns to support Lyme disease treatment or diagnosis to identify whether or not any common elements shared in these narratives exist, and if so, what they are. We identified 238 campaigns for inclusion from three prominent crowdfunding platforms. Thematic analysis of the campaign narratives shows four consistent themes shared in these campaigns: what is lost (e.g. bodily ability), what is missing (e.g. local care options), what is sought (e.g. funds to cover treatment abroad) and what is hoped for (e.g. return to wellbeing). These themes demonstrate the highly personal and emotional nature of medical crowdfunding, particularly in the context of a contested illness that may lead some to question the legitimacy of one's financial need. This analysis contributes valuable new insights to the nascent scholarship on medical crowdfunding, and particularly to our understanding of how people communicate about their health and bodily needs on this public platform. It also identifies important directions for future research, including the potential for crowdfunding narratives to be used for advocacy.

How the design and implementation of centralized waiting lists influence their use and effect on access to healthcare - A realist review.

CONTEXT: Many health systems have centralized waiting lists (CWLs), but there is limited evidence on CWL effectiveness and how to design and implement them. AIM: To understand how CWLs' design and implementation influence their use and effect on access to healthcare. METHODS: We conducted a realist review (n = 21 articles), extracting context-intervention-mechanism-outcome configurations to identify demi-regularities (i.e., recurring patterns of how CWLs work). RESULTS: In implementing non-mandatory CWLs, acceptability to providers influences their uptake of the CWL. CWL eligibility criteria that are unclear or conflict with providers' role or judgement may result in inequities in patient registration. In CWLs that prioritize patients, providers must perceive the criteria as clear and appropriate to assess patients' level of need; otherwise, prioritization may be inconsistent. During patients' assignment to service providers, providers may select less-complex patients to obtain CWLs rewards or avoid penalties; or may select patients for other policies with stronger incentives, disregarding the established patient order and leading to inequities and limited effectiveness. CONCLUSION: These findings highlight the need to consider provider behaviours in the four sequential CWL design components: CWL implementation, patient registration, patient prioritization and patient assignment to providers. Otherwise, CWLs may result in limited effects on access or lead to inequities in access to services.

Where to enhance rural palliative care? Developing a spatial model to identify suitable communities most in need of service enhancement.

BACKGROUND: In Canada, access to palliative care is a growing concern, particularly in rural communities. These communities have constrained health care services and accessing local palliative care can be challenging. The Site Suitability Model (SSM) was developed to identify rural "candidate" communities with need for palliative care services and existing health service capacity that could be enhanced to support a secondary palliative care hub. The purpose of this study was to test the feasibility of implementing the SSM in Ontario by generating a ranked summary of rural "candidate" communities as potential secondary palliative care hubs. METHODS: Using Census data combined with community-level data, the SSM was applied to assess the suitability of 12 communities as rural secondary palliative care hubs. Scores from 0 to 1 were generated for four equally-weighted components: (1) population as the total population living within a 1-h drive of a candidate community; (2) isolation as travel time from that community to the nearest community with palliative care services; (3) vulnerability as community need based on a palliative care index score; and (4) community readiness as five dimensions of fit between a candidate community and a secondary palliative care hub. Component scores were summed for the SSM score and adjusted to range from 0 to 1. RESULTS: Population scores for the 12 communities ranged widely (0.19-1.00), as did isolation scores (0.16-0.94). Vulnerability scores ranged more narrowly (0.27-0.35), while community readiness scores ranged from 0.4-1.0. These component scores revealed information about each community's particular strengths and weaknesses. Final SSM scores ranged from a low of 0.33 to a high of 0.76. CONCLUSIONS: The SSM was readily implemented in Ontario. Final scores generated a ranked list based on the relative suitability of candidate communities to become secondary palliative care hubs. This list provides information for policy makers to make allocation decisions regarding rural palliative services. The calculation of each community's scores also generates information for local policy makers about how best to provide these services within their communities. The multi-factorial structure of the model enables decision makers to adapt the relative weights of its components.

Facilitating equitable community-level access to maternal health services: exploring the experiences of Rwanda's community health workers.

BACKGROUND: In Rwanda, community health workers (CHWs) are an integral part of the health system. For maternal health, CHWs are involved in linking members of the communities in which they live to the formal health care system to address preventative, routine, and acute maternal care needs. Drawing on the findings from in-depth interviews with maternal health CHWs and observational insights in ten Rwandan districts, we identify specific strategies CHWs employ to provide equitable maternal care while operating in a low resource setting. METHODS: Using case study methodology approach, we conducted interviews with 22 maternal health CHWs to understand the nature of their roles in facilitating equitable access to maternal care in Rwanda at the community level. Interviews were conducted in five Rwandan districts. Participants shared their experiences of and perceptions on promoting equitable access to maternal health service in their communities. RESULTS: Four key themes emerged during the analytic process that characterize the contexts and strategic ways in which maternal health CHWs facilitate equitable access to maternal care in an environment of resource scarcity. They are: 1) community building; 2) physical landscapes, which serve as barriers or facilitators both to women's care access and CHWs' equitable service provision; 3) the post-crisis socio-political environment in Rwanda, which highlights resilience and the need to promote maternal health subsequent to the genocide of 1994; and, 4) the strategies used by CHWs to circumvent the constraints of a resource-poor setting and provide equitable maternal health services at the community level. CONCLUSION: Rwanda's maternal CHWs are heavily responsible for promoting equitable access to maternal health services. Consequently, they may be required to use their own resources for their practice, which could jeopardize their own socio-economic welfare and capacity to meet the demands of their families. Considering the unpaid and untrained nature of this position, we highlight the factors that threaten the sustainability of CHWs' role to facilitate equitable access to maternal care. These threats introduce turbulence into what is a relatively successful community-level health care initiative.

"Medical tourism will obligate physicians to elevate their level so that they can compete": a qualitative exploration of the anticipated impacts of inbound medical tourism on health human resources in Guatemala.

BACKGROUND: Medical tourism, which involves cross-border travel to access private, non-emergency medical interventions, is growing in many Latin American Caribbean countries. The commodification and export of private health services is often promoted due to perceived economic benefits. Research indicates growing concern for health inequities caused by medical tourism, which includes its impact on health human resources, yet little research addresses the impacts of medical tourism on health human resources in destination countries and the subsequent impacts for health equity. To address this gap, we use a case study approach to identify anticipated impacts of medical tourism sector development on health human resources and the implications for health equity in Guatemala. METHODS: After undertaking an extensive review of media and policy discussions in Guatemala's medical tourism sector and site visits observing first-hand the complex dynamics of this sector, in-depth key informant interviews were conducted with 50 purposefully selected medical tourism stakeholders in representing five key sectors: public health care, private health care, health human resources, civil society, and government. Participants were identified using multiple recruitment methods. Interviews were transcribed in English. Transcripts were reviewed to identify emerging themes and were coded accordingly. The coding scheme was tested for integrity and thematic analysis ensued. Data were analysed thematically. RESULTS: Findings revealed five areas of concern that relate to Guatemala's nascent medical tourism sector development and its anticipated impacts on health human resources: the impetus to meet international training and practice standards; opportunities and demand for English language training and competency among health workers; health worker migration from public to private sector; job creation and labour market augmentation as a result of medical tourism; and the demand for specialist care. These thematic areas present opportunities and challenges for health workers and the health care system. CONCLUSION: From a health equity perspective, the results question the responsibility of Guatemala's medical education system for supporting an enhanced medical tourism sector, particularly with an increasing focus on the demand for private clinics, specific specialities, English-language training, and international standards. Further, significant health inequalities and barriers to care for Indigenous populations are unlikely to benefit from the impacts identified from participants, as is true for rural-urban and public-private health human resource migration.

Government roles in regulating medical tourism: evidence from Guatemala.

BACKGROUND: Regulation of the medical tourism and public health sectors overlap in many instances, raising questions of how patient safety, economic growth, and health equity can be protected. The case of Guatemala is used to explore how the regulatory challenges posed by medical tourism should be dealt with in countries seeking to grow this sector. METHODS: We conducted a qualitative case study of the medical tourism sector in Guatemala, through reviews and analyses of policy documents and media reports, key informant interviews (n = 50), and facility site-visits. RESULTS: Key informants were critical of the absence of effective public regulation of the emerging medical tourism sector, noting several regulatory gaps and the importance of filling them. These informants specifically expressed that: 1) The government should regulate medical tourism in Guatemala, thought there was disagreement as to which government sector should do so and how; 2) The government has not at this time regulated the medical tourism sector nor shown great interest in doing so; and 3) International accreditation could be used to augment domestic regulation. CONCLUSIONS: The intersection of domestic and international regulation of medical tourism has been largely unexplored. This case study advances new research in this area. It highlights the need for and dearth of regulatory protections in Guatemala and lessons for other, similarly situated countries. National regulatory models from Israel and Barbados could be adapted to the Guatemalan context. Global governance could help to protect national governments from any competitive disadvantages created by regulation. Underlying the concerns over growth in medical tourism, however, is how it contributes to the ongoing privatization of health care facilities worldwide. This trend risks undermining efforts to reach targets for Universal Health Coverage and exacerbating existing inequities in the global distribution of health and wealth.

A critical examination of empowerment discourse in medical tourism: the case of the dental tourism industry in Los Algodones, Mexico.

BACKGROUND: Medical tourism is a term used to describe the phenomenon of individuals intentionally traveling across national borders to privately purchase medical care. The medical tourism industry has been portrayed in the media as an "escape valve" providing alternative care options as a result of vast economic asymmetries between the global north and global south and the flexible regulatory environment in which care is provided to medical tourists. Discourse suggesting the medical tourism industry necessarily enhances access to medical care has been employed by industry stakeholders to promote continued expansion of the industry; however, it remains unknown how this discourse informs industry practices on the ground. Using case study methodology, this research examines the perspectives and experiences of industry stakeholders working and living in a dental tourism industry site in northern Mexico to develop a better understanding of the ways in which common discourses of the industry are taken up or resisted by various industry stakeholders and the possible implications of these practices on health equity. RESULTS: Interview discussions with a range of industry stakeholders suggest that care provision in this particular location enables international patients to access high quality dental care at more affordable prices than typically available in their home countries. However, interview participants also raised concerns about the quality of care provided to medical tourists and poor access to needed care amongst local populations. These concerns disrupt discourses about the positive health impacts of the industry commonly circulated by industry stakeholders positioned to profit from these unjust industry practices. CONCLUSIONS: We argue in this paper that elite industry stakeholders in our case site took up discourses of medical tourism as enhancing access to care in ways that mask health equity concerns for the industry and justify particular industry activities despite health equity concerns for these practices. This research provides new insight into the ways in which the medical tourism industry raises ethical concern and the structures of power informing unethical practices.

The development of a spatial palliative care index instrument for assessing population-level need for palliative care services.

We developed an index to measure potential need for palliative care services (PCIX). This is an instrument that enables spatial identification of potential population-level need for palliative care services and can be developed using census data. Four indicators of potential need for palliative care services -age, sex, living arrangement, socio-economic status (SES)-were used to produce composite potential need scores for DAs. Scores were graphically mapped, producing a spatial delineation of relative need for end-of-life services. To assess the benefit of combining multiple variables to define potential need, PCIX resolution was compared to general SES-based delineations of need. PCIX scores and maps were generated for all DAs, revealing spatial variability in potential need for palliative care services (PCS). Comparison of PCIX maps to those based on purely on SES indicated that use of variables specifically linked to palliative need resulted in more precise delineations of potential populations in need of PCS. Using composite scores - based on freely available census data - to spatially assess potential need for palliative care services can provide critical data for decision makers charged with rationalizing service locations and service capacity.

What does the development of medical tourism in Barbados hold for health equity? an exploratory qualitative case study.

BACKGROUND: Although the global growth of privatized health care services in the form of medical tourism appears to generate economic benefits, there is debate about medical tourism's impacts on health equity in countries that receive medical tourists. Studies of the processes of economic globalization in relation to social determinants of health suggest that medical tourism's impacts on health equity can be both direct and indirect. Barbados, a small Caribbean nation which has universal public health care, private sector health care and a strong tourism industry, is interested in developing an enhanced medical tourism sector. In order to appreciate Barbadians' understanding of how a medical tourism industry might impact health equity. METHODS: We conducted 50 individual and small-group interviews in Barbados with stakeholders including government officials, business and health professionals. The interviews were coded and analyzed deductively using the schedule's questions, and inductively for novel findings, and discussed by the authors. RESULTS: The findings suggest that in spite of Barbados' universal health care and strong population health indicators, there is expressed concern for medical tourism's impact on health equity. Informants pointed to the direct ways in which the domestic population might access more health care through medical tourism and how privately-provided medical tourism in Barbados could provide health benefits indirectly to the Barbadian populations. At the same time, they cautioned that these benefits may not materialize. For example, the transfer of public resources - health workers, money, infrastructure and equipment - to the private sector to support medical tourism with little to no return to government revenues could result in health inequity through reductions in access to and availability of health care for residents. CONCLUSIONS: In clarifying the direct and indirect pathways by which medical tourism can impact health equity, these findings have implications for health system stakeholders and decision-makers in Barbados and other countries attempting both to build a medical tourism industry and to protect health equity.

"Stay cool, sell stuff cheap, and smile": Examining how reputational management of dental tourism reinforces structural oppression in Los Algodones, Mexico.

Los Algodones, Mexico is characteristic of other medical border towns whose proximity to the Mexico-United States border enables American and Canadian patients to take advantage of economic asymmetries on either side of the border to access desired health care. Los Algodones is unique, however, in its focus on the provision of dental care and claims by local residents that it has the highest concentration of dentists per capita in the world. In this paper, we present an analysis of interviews with employees working in Los Algodones' dental tourism industry to examine interviewees' participation in practices related to reputational management of the industry site. Drawing on our interview discussions, we argue that many of these reputational management practices reinforce structural injustices and raise concerns for structural exploitation in the industry. This analysis nuances ethical considerations for medical tourism by highlighting structural factors informing unjust practices within the industry, factors which might be relevant to other medical tourism contexts.

Pills in paradise: Exploring international lifestyle and retirement migrants' perceptions of the pharmaceutical sector on Cozumel Island, Mexico.

International lifestyle and retirement migration is a growing phenomenon, yet little is known about migrants' experiences of health care in destination countries. This includes use of and access to pharmaceutical selling establishments. This article explores international lifestyle and retirement migrants' experiences and perceptions of the local pharmaceutical sector on Cozumel Island, Mexico. Qualitative data, collected through semi-structured interviews (n = 26), finds that participants are concerned with accessibility, quality and communication within the island's pharmaceutical sector. Subsequent analysis suggests that these concerns arise through comparison with previous health care environments and that migrants attempt to remedy them by spatially reorganising their pharmacy engagements through practices which may contribute to adverse health outcomes.

Developing an informational tool for ethical engagement in medical tourism.

BACKGROUND: Medical tourism, the practice of persons intentionally travelling across international boundaries to access medical care, has drawn increasing attention from researchers, particularly in relation to potential ethical concerns of this practice. Researchers have expressed concern for potential negative impacts to individual safety, public health within both countries of origin for medical tourists and destination countries, and global health equity. However, these ethical concerns are not discussed within the sources of information commonly provided to medical tourists, and as such, medical tourists may not be aware of these concerns when engaging in medical tourism. This paper describes the methodology utilized to develop an information sheet intended to be disseminated to Canadian medical tourists to encourage contemplation and further public discussion of the ethical concerns in medical tourism. METHODS: The methodology for developing the information sheet drew on an iterative process to consider stakeholder feedback on the content and use of the information sheet as it might inform prospective medical tourists' decision making. This methodology includes a literature review as well as formative research with Canadian public health professionals and former medical tourists. RESULTS: The final information sheet underwent numerous revisions throughout the formative research process according to feedback from medical tourism stakeholders. These revisions focused primarily on making the information sheet concise with points that encourage individuals considering travelling for medical tourism to do further research regarding their safety both within the destination country, while travelling, and once returning to Canada, and the potential impacts of their trip on third parties. This methodology may be replicated for the development of information sheets intending to communicate ethical concerns of other practices to providers or consumers of a certain service.

Reflections on 'medical tourism' from the 2016 Global Healthcare Policy and Management Forum.

In October 2016, the Global Healthcare Policy and Management Forum was held at Yonsei University, Seoul, South Korea. The goal of the forum was to discuss the role of the state in regulating and supporting the development of medical tourism. Forum attendees came from 10 countries. In this short report article, we identify key lessons from the forum that can inform the direction of future scholarly engagement with medical tourism. In so doing, we reference on-going scholarly debates about this global health services practice that have appeared in multiple venues, including this very journal. Key questions for future research emerging from the forum include: who should be meaningfully involved in identifying and defining categories of those travelling across borders for health services and what risks exist if certain voices are underrepresented in such a process; who does and does not 'count' as a medical tourist and what are the implications of such quantitative assessments; why have researchers not been able to address pressing knowledge gaps regarding the health equity impacts of medical tourism; and how do national-level polices and initiatives shape the ways in which medical tourism is unfolding in specific local centres and clinics? This short report as an important time capsule that summarises the current state of medical tourism research knowledge as articulated by the thought leaders in attendance at the forum while also pushing for research growth.

"Location is surprisingly a lot more important than you think": a critical thematic analysis of push and pull factor messaging used on Caribbean offshore medical school websites.

BACKGROUND: Offshore medical schools are for-profit, private enterprises located in the Caribbean that provide undergraduate medical education to students who must leave the region for postgraduate training and also typically to practice. This growing industry attracts many medical students from the US and Canada who wish to return home to practice medicine. After graduation, international medical graduates can encounter challenges obtaining residency placements and can face other barriers related to practice. METHODS: We conducted a qualitative thematic analysis to discern the dominant messages found on offshore medical school websites. Dominant messages included frequent references to push and pull factors intended to encourage potential applicants to consider attending an offshore medical school. We reviewed 38 English-language Caribbean offshore medical school websites in order to extract and record content pertaining to push and pull factors. RESULTS: We found two push and four pull factors present across most offshore medical school websites. Push factors include the: shortages of physicians in the US and Canada that require new medical trainees; and low acceptance rates at medical schools in intended students' home countries. Pull factors include the: financial benefits of attending an offshore medical school; geographic location and environment of training in the Caribbean; training quality and effectiveness; and the potential to practice medicine in one's home country. CONCLUSIONS: This analysis contributes to our understanding of some of the factors behind students' decisions to attend an offshore medical school. Importantly, push and pull factors do not address the barriers faced by offshore medical school graduates in finding postgraduate residency placements and ultimately practicing elsewhere. It is clear from push and pull factors that these medical schools heavily focus messaging and marketing towards students from the US and Canada, which raises questions about who benefits from this offshoring practice.

Appealing to the crowd: ethical justifications in Canadian medical crowdfunding campaigns.

Medical crowdfunding is growing in terms of the number of active campaigns, amount of funding raised and public visibility. Little is known about how campaigners appeal to potential donors outside of anecdotal evidence collected in news reports on specific medical crowdfunding campaigns. This paper offers a first step towards addressing this knowledge gap by examining medical crowdfunding campaigns for Canadian recipients. Using 80 medical crowdfunding campaigns for Canadian recipients, we analyse how Canadians justify to others that they ought to contribute to funding their health needs. We find the justifications campaigners tend to fall into three themes: personal connections, depth of need and giving back. We further discuss how these appeals can understood in terms of ethical justifications for giving and how these justifications should be assessed in light of the academic literature on ethical concerns raised by medical crowdfunding.

A comparative analysis of centralized waiting lists for patients without a primary care provider implemented in six Canadian provinces: study protocol.

BACKGROUND: Having a regular primary care provider (i.e., family physician or nurse practitioner) is widely considered to be a prerequisite for obtaining healthcare that is timely, accessible, continuous, comprehensive, and well-coordinated with other parts of the healthcare system. Yet, 4.6 million Canadians, approximately 15% of Canada's population, are unattached; that is, they do not have a regular primary care provider. To address the critical need for attachment, especially for more vulnerable patients, six Canadian provinces have implemented centralized waiting lists for unattached patients. These waiting lists centralize unattached patients' requests for a primary care provider in a given territory and match patients with providers. From the little information we have on each province's centralized waiting list, we know the way they work varies significantly from province to province. The main objective of this study is to compare the different models of centralized waiting lists for unattached patients implemented in six provinces of Canada to each other and to available scientific knowledge to make recommendations on ways to improve their design in an effort to increase attachment of patients to a primary care provider. METHODS: A logic analysis approach developed in three steps will be used. Step 1: build logic models that describe each province's centralized waiting list through interviews with key stakeholders in each province; step 2: develop a conceptual framework, separate from the provincially informed logic models, that identifies key characteristics of centralized waiting lists for unattached patients and factors influencing their implementation through a literature review and interviews with experts; step 3: compare the logic models to the conceptual framework to make recommendations to improve centralized waiting lists in different provinces during a pan Canadian face-to-face exchange with decision-makers, clinicians and researchers. DISCUSSION: This study is based on an inter-provincial learning exchange approach where we propose to compare centralized waiting lists and analyze variations in strategies used to increase attachment to a regular primary care provider. Fostering inter-provincial healthcare systems connectivity to improve centralized waiting lists' practices across Canada can lever attachment to a regular provider for timely access to continuous, comprehensive and coordinated healthcare for all Canadians and particular for those who are vulnerable.