Civil service organization as a political determinant of health: Analyzing relationships between merit-based hiring, corruption, and population health.

A growing literature finds that the way governments are organized can impact the societies they serve in important ways. The same is apparent with respect to civil service organizations. Numerous studies show that the recruitment of civil servants based on their credentials rather than on nepotism or patronage reduces corruption in government. Political corruption in turn appears to harm population health. Up to this time, however, civil service organization is not a recognized determinant of health and is little discussed outside of political science disciplines. To provoke a broader conversation on this subject, the following study proposes that meritocratic recruitment of civil servants improves population health. To test this proposition, a series of regression models examines comparative data for 118 countries. Consistent with study hypotheses, meritocratic recruitment of civil servants corresponds longitudinally with both lower rates of corruption and lower rates of infant mortality. Results are similar after robustness checks. Findings with regard to life expectancy are more mixed. However, additional tests suggest meritocratic recruitment contributes to life expectancy over a longer span of time. Findings also offer more support for a direct pathway from meritocratic recruitment to population health rather than via changes in corruption levels per se, although this may depend on a country's level of economic development. Overall, this study offers first evidence that civil service organization, particularly the recruitment of civil servants based on the merits of their applications rather than on whom they happen to know in government, is a positive determinant of health. More research in this area is needed.

Willingness to Pay for Social Health Insurance and Its Predictors among Government Employees in Mujja Town, Ethiopia.

BACKGROUND: Social health insurance is one of the possible organizational mechanisms for raising and pooling funds to finance health services, private health insurance, community insurance, and others. OBJECTIVE: The study was aimed to assess willingness to pay for social health insurance and associated factors among government employees in Mujja town, Ethiopia. METHODS: An institutional-based cross-sectional study was conducted on the total sample size of 375 study respondents. A simple random sampling technique was employed. Data were entered into EPI info 7 and analyzed by Statistical Package for Social Sciences version 22.0. Multivariable logistic regression was used to identify independent predictors by controlling confounding variables. Statistical significance was declared at p < 0.05. RESULTS: This study revealed that 37.6% (95% CI: 33.1%, 42.61%) respondents were willing to pay for social health insurance. In the final model, respondents who ever heard about health insurance schemes were seven times (AOR = 7.205; 95% CI: 1.385, 37.475) more likely willing to pay for social health insurance. Thos who had history of difficulty and having other source to cover medical bills were 92.6% (AOR = 0.074; 95% CI: 0.009, 0.612) and 94.6% (AOR = 0.054; 95% CI: 0.011, 0.257) less likely to pay, respectively. CONCLUSIONS: Willingness to pay for social health insurance was low. Being heard about health insurance, history of difficulty, and having other sources to cover medical bills were associated factors. Thus, it is recommended that media promotion and these factors should be considered for the successful implementation of the scheme.

O trabalho no campo da educação: o Fórum-Cosate como estratégia de resistência à máquina neoliberal / Labor in the field of education: fórum-cosate as a strategy of resistance against the neoliberal machine

O artigo introduz uma experiência de pesquisa-intervenção realizada na região metropolitana de Vitória, Espírito Santo, mais especificamente no município de Serra visando ao fortalecimento de práticas no contexto escolar que possam fazer frente à racionalidade neoliberal que toma a educação como bem privado de valor econômico. Apresenta a constituição de um fórum de trabalhadores da educação cujo objetivo é construir estratégias que possam desafiar o processo de adoecimento em curso nas escolas, decorrente da racionalidade econômica vigente no referido município. Aponta como direção ética a indissociabilidade entre clínica e política e aposta na criação de táticas coletivas de enfrentamento ao adoecimento nas unidades escolares da rede.

This article presents the experience of a research-intervention carried out in the municipality of Serra, metropolitan region of Vitória, Espírito Santo, aiming to strengthen practices in the school context that can face the neoliberal rationality that considers education as private goods of economic value. It describes the constitution of a forum for education workers to develop strategies that could challenge the sickness process underway in schools, due to the economics-guided thinking in that municipality. Its ethical direction, the inseparability between clinic and politics as well as the investment in the creation of collective tactics to fight sickness in the school units of the city are highlighted.

State Lawmaker's Views on Childhood Obesity and Related School Wellness Legislation.

BACKGROUND: School wellness legislation has potential to impact the health of children and alter the obesity crisis in the United Sates. Little is known about how state lawmakers perceive child wellness legislation effectiveness relative to obesity prevention. Our purpose was to understand state lawmakers' perceptions of childhood obesity and school wellness policies relative to the Social Ecological Model (SEM). METHODS: Twenty-one state representatives and nine state senators from one US state completed in-depth interviews. Member checks and peer debriefing occurred throughout data collection and analysis. Transcripts were coded and triangulated. A conventional content analysis generated consistent themes. RESULTS: Five main themes developed: (1) child overweight and obesity is problematic; (2) current legislation is ineffective; (3) funding and enforcing child wellness legislation is difficult; (4) it is difficult to legislate personal behavior; and (5) efforts from other levels of the SEM are more effective at promoting wellness. CONCLUSIONS: Lawmakers understand negative impacts of child obesity, but perceive immediate legislative issues like budgetary concerns inhibit robust policy-oriented action. Participants believe parents, guardians, and individuals should ultimately be responsible for child wellness. Community, school, and family efforts to address childhood obesity and support wellness may be more effective in achieving positive outcomes than state and federal policy.

Fieldwork-based determination of design priorities for point-of-use drinking water quality sensors for use in resource-limited environments.

Improved capabilities in microfluidics, electrochemistry, and portable assays have resulted in the development of a wide range of point-of-use sensors intended for environmental, medical, and agricultural applications in resource-limited environments of developing countries. However, these devices are frequently developed without direct interaction with their often-remote intended user base, creating the potential for a disconnect between users' actual needs and those perceived by sensor developers. As different analytical techniques have inherent strengths and limitations, effective measurement solution development requires determination of desired sensor attributes early in the development process. In this work, we present our findings on design priorities for point-of-use microbial water sensors based on fieldwork in rural India, as well as a guide to fieldwork methodologies for determining desired sensor attributes. We utilized group design workshops for initial identification of design priorities, and then conducted choice-based conjoint analysis interviews for quantification of user preferences among these priorities. We found the highest user preference for integrated reporting of contaminant concentration and recommended actions, as well as significant preferences for mostly reusable sensor architectures, same-day results, and combined ingredients. These findings serve as a framework for future microbial sensor development and a guide for fieldwork-based understanding of user needs.

Doctors Rule: An Analysis of Health Ministers' Diaries in Australia.

Limited progress in nutrition policy action is often blamed on the close relationships the food industry has with health policy decision-makers. This analysis sought to examine this belief through the analysis of health ministers' diaries. Entries were downloaded from health ministers' diaries from two states in Australia from January 2013 to June 2018. Entries were coded according to which interest group met with the minister or whether general parliamentary business was undertaken. Coding was also undertaken for any meeting topics related to nutrition policy. Analysis of health ministers' diaries found that the food industry has limited documented interaction with the two state health ministers in Australia. Instead, medical associations, private hospitals and health services, and sporting associations (rugby league associations) had the most interactions with health ministers. Poor representation was seen on nutrition issues, and there was an apparent lack of nutrition advocates interacting with the health ministers. There are opportunities for nutrition advocates to increase their level of interaction with state health ministers. This could include building alliances with medical associations, as they are in a powerful position, to advocate directly to health ministers. Health ministers' diaries can provide valuable insights into who is meeting officially with ministers. However, there are also limitations with the dataset.

Comparisons in the attitudes toward suicide among urban residents, lawmakers and community mental health workers in South Korea.

The attitudes of the general public and lawmakers toward suicide can influence the degree to which suicide prevention is prioritized in public policymaking. In this study, we compared the attitudes of urban residents, lawmakers, and community mental health workers toward suicide. Urban residents (N = 501) were surveyed through a telephone interview, while self-reported questionnaire was administered by lawmakers (N = 156) and community mental health workers (N = 121) through office visit and post, respectively. We used the Suicide Opinion Questionnaire to measure attitudes toward suicide in all three samples. Both the general public and legislators had insufficient knowledge and more permissive and uncaring attitudes toward suicide, whereas community mental health workers were more inclined to have sufficient knowledge of suicide and more intolerant and caring attitudes towards suicide. Therefore, lawmakers and the general public require education on suicide and suicide prevention, which may help lower South Korea's high suicide rate ranking among the Organization for Economic Co-operation and Development member states.

Impact of Forced Migration on Communication and Social Adaptation.

Forced migration has spread and grown across continents in recent decades. This has had an impact at various levels such as societal communication, health and education priorities, as well as political agendas and economic stability. As a result of the combined forces of migration, globalisation, advances in communication technology and education, there is an exceptional research interest in individuals seeking refugee status or asylum. The literature is sporadic on forced migrants' communication and social adaptation. The perception of residents and professionals who encounter the challenges faced by these individuals on a regular basis needs to be evaluated, as well as the perception of the migrants themselves. This paper presents the current state of affairs and reviews the relevant literature with the intention of providing a more coordinated overview of forced migrants' and relevant stakeholders' views. A case scenario is presented that discusses the communication challenges faced by forced migrants. Strategic recommendations are also discussed.

Improving Medicaid Access in Times of Health Policy Change: Solutions from Focus Groups with Frontline Enrollment Workers.

Enrollment navigators and government-employed Medicaid workers were an important element in the Affordable Care Act's (ACA) initial enrollment success. The Centers for Medicare and Medicaid Services eliminated 41% of funding for 2017 navigator programs and 90% of funding for outreach, arguing less investment was needed. Given that many remain uninsured, it is critical to identify effective enrollment practices. This study characterizes barriers and enrollment strategies from the perspective of California's Medicaid government and community-based enrollment workers (n=101 in eight focus groups). Participants identified a need for communication with policymakers, the state exchange, and each other regarding changing enrollment processes. Solutions include increased contact between enrollment workers to share strategies and policy updates regarding application processing, uniform policy interpretation, and details of ACA-related immigration law. Given efforts to weaken the ACA, it is critical to engage frontline workers in problem solving to streamline enrollment strategies, particularly for vulnerable populations.

Prevalence and context of racism experienced by older Aboriginal and Torres Strait Islanders.

OBJECTIVE: To examine the prevalence and context of racism self-reported by older Aboriginal and Torres Strait Islander people. METHODS: The 2015 National Aboriginal and Torres Strait Islander Survey was used to measure the prevalence, contexts and demographic differences in reports of racism. Multivariable logistic regression was used to examine the association of age with racism in later life. RESULTS: A sizeable minority of older Aboriginal people reported experiences of unfair treatment (31%) and avoidance (15%), oftentimes occurring in contexts critical to human capital investments. Specific demographic groups, including those with higher levels of education, were more likely to report experiences of unfair treatment. The prevalence of unfair treatment and avoidance remains relatively high in later life (albeit lower than younger ages), with a significant reduction from age 65. CONCLUSION: Addressing racism, particularly in contexts crucial to human capital, is important for the health and well-being of older Aboriginal people.

Bureaucratic power in note-writing: authoritative expertise within the state.

What produces the power of senior civil servants at ministries of finance, positioned at the top of the bureaucratic hierarchy? Max Weber has claimed that a hierarchical organization, meritocratic recruitment and procedural work provide bureaucracies with legitimacy. In particular he insisted on the role of Fachwissen (disciplinary knowledge) obtained through formal education. However, he also argued for the role of Dienstwissen, forms of knowledge and skills stemming from the experience of service in itself. Weber did not elaborate on this concept in detail, and few analysts of governmental expertise have examined this notion. We draw on the practice-turn in sociology, combining the study of governmental expertise with micro-sociological studies of administrative practices. By analysing interviews with 48 senior civil servants at the British, French and Norwegian ministries of finance about their daily practices, this article demonstrates that bureaucratic note-writing and the procedural evaluation of such notes constitute a key form of expertise that yields authority. The study provides an analytical framework for understanding what administrative expertise consists of, how it is integral to procedural work, the forms bureaucratic hierarchies take in practice and how these three dimensions provide authority.

The association between subordinate perception of task and relation oriented leadership behaviors and sense of coherence among a sample of Swedish white-collar workers.

BACKGROUND: Evidence suggests that leadership behaviors and sense of coherence (SOC) influences subordinate health. However, this has not been investigated in any detail. OBJECTIVES: To study the association between leadership behaviors and SOC. It was hypothesized that both task and relation oriented leadership behaviors would be positively associated with SOC, whereas a laissez-faire leadership would be negatively associated with SOC. METHODS: This is a cross-sectional quantitative study of managers and subordinates in a large governmental organization. The study used two common and empirically tested leadership styles: task oriented leadership and relation oriented leadership. In a logistic regression analysis, the association between types of leadership behavior and SOC were analyzed while controlling for age, gender, income, type of employment and organizational tenure. RESULTS: Neither task oriented or relation oriented leadership behavior were significantly associated with SOC. CONCLUSIONS: The result indicates that the type of leadership behavior exercised is not directly associated with subordinate's SOC. In future studies the importance of subordinate leadership preferences should be acknowledged. More research is needed to reach an understanding as to the nature of and the potential of this mechanism.

Policies of attention to the elderly according to the voice of the municipal managers of health. / Políticas de atenção a idosos na voz de gestores municipais de saúde.

OBJECTIVE: To analyze the understanding of municipal managers of health about public policies destined to the elderly population and the way they are effected in the city. METHOD: Qualitative study, developed with 14 municipal managers of health. Data were collected through a semi-structured interview and analyzed according the precepts of content analysis. RESULTS: The results show the lack of knowledge of the municipal health managers, related to public policies of attention to the elderly. Also, the attention given to the elderly in the studied municipalities focuses on measures to control health problems. CONCLUSION: The municipalities do not have specific health care policies for the elderly population. Thus, these results can support reflections about care for the elderly in health services, their relationship with legislation, and the applicability of public health policies.

Identifying Windows of Opportunity for Active Living and Healthy Eating Policies in Connecticut, 2016.

We examined the relative importance of 23 community issues among elected officials and health directors in Connecticut in 2016. For this cross-sectional study, 74 elected officials (40.7% response rate) and 47 health directors (62.7% response rate), who were purposively sampled, completed a questionnaire to rate their perceived importance of 23 community issues. Eight of these issues were related to active living, healthy eating, or obesity. We used χ2 tests to evaluate differences in responses. Compared with elected officials, health directors significantly more often perceived obesity, access to healthy groceries, poor nutrition, lack of pedestrian walkways, and pedestrian safety as important. Elected officials significantly more often than health directors perceived lack of good jobs, quality of public education, and cost of living as important. Health advocates should work with both groups to develop and frame policies to address both upstream (eg, jobs, education) and downstream (eg, healthy eating policies) determinants of obesity.

Retirement and Socioeconomic Differences in Diurnal Cortisol: Longitudinal Evidence From a Cohort of British Civil Servants.

Objectives: Early old age and the period around retirement are associated with a widening in socioeconomic inequalities in health. There are few studies that address the stress-biological factors related to this widening. This study examined whether retirement is associated with more advantageous (steeper) diurnal cortisol profiles, and differences in this association by occupational grade. Method: Data from the 7th (2002-2004), 8th (2006), and 9th (2007-09) phases of the London-based Whitehall II civil servants study were analysed. Thousand hundred and forty three respondents who were employed at phase 8 (mean age 59.9 years) and who had salivary cortisol measured from five samples collected across the day at phases 7 and 9 were analysed. Results: Retirement was associated with steeper diurnal slopes compared to those who remained in work. Employees in the lowest grades had flatter diurnal cortisol slopes compared to those in the highest grades. Low-grade retirees in particular had flatter diurnal slopes compared to high-grade retirees. Discussion: Socioeconomic differences in a biomarker associated with stress increase, rather than decrease, around the retirement period. These biological differences associated with transitions into retirement for different occupational groups may partly explain the pattern of widening social inequalities in health in early old age.

Qualidade de vida e fatores associados em aposentados por invalidez de uma universidade pública brasileira / Calidad de vida y factores asociados en jubilados por invalidez de una universidad pública brasileña / Quality of life and associated factors in retirees due to disability in a brazilian public university

RESUMO Objetivo: Avaliar a Qualidade de Vida e os fatores associados em servidores aposentados por invalidez de uma universidade pública. Material e método: Estudo analítico realizado com 40 servidores aposentados por invalidez entre 2000 e 2014 de uma universidade pública brasileira. Foi utilizado um questionário para obtenção dos dados de caracterização dos participantes e o Short Form Health Survey (SF36v2) para avaliar a qualidade de vida. Para análise estatística utilizou-se regressão linear múltipla pela técnica de Bootstrap. Resultados: Os aposentados apresentaram escores médios de qualidade de vida de 42,3 (DP 12,1) no componente físico e 41,1 (DP 16,4) no mental. As menores percepções nos domínios de qualidade de vida estiveram associadas sobretudo às doenças crônicas, enquanto que as melhores percepções de alguns domínios foram associadas ao lazer e pos suir relacionamento conjugal. Conclusão: Os participantes apresentaram uma qualidade de vida insatisfatória. Faz-se necessário o controle das doenças crônicas, estímulo aos hábitos de vida saudáveis e promoção de saúde, a fim de melhorar a qualidade de vida destas pessoas.

ABSTRACT Objective: To evaluate the Quality of Life and the associated factors in civil servants retired due to disability. Method: Analytical study with 40 retired public employees due to disability from a Brazilian public university between the years 2000-2014. A questionnaire was used to obtain the data characterizing the participants, and the Short Form Health Survey (SF36v2) was used to evaluate their quality of life. For statistical analysis, multi ple linear regression and bootstrapping were used. Results: Disabled retirees presented mean scores of 42.3 (DS 12.1) in the physical component and 41.1 (DS 16.4) in the mental component. The lower perceptions in the domains of quality of life were mainly associated with chronic disease, while the highest perceptions of some domains were associated with leisure and being in a marital relationship. Conclusion: The participants presented an unsatisfactory quality of life. It is necessary to control chronic diseases, stimulate healthy living habits and promote health in order to improve the quality of life of these people.

RESUMEN Objetivo: Evaluar la Calidad de Vida y los factores asociados en los empleados jubilados por incapacidad de una universidad pública. Material y método: Estudio analítico con 40 empleados jubilados por discapacidad entre los años 2000-2014 de una universidad pública brasileña. Se utilizó un cuestionario para la obtención de los datos de caracterización de los participantes y Short Form Health Survey (SF36v2) para evaluar la calidad de vida. El análisis estadístico se realizó mediante regresión lineal múltiple por Bootstrap. Resultados: Los jubilados por discapacidad tuvieron puntuaciones medias en calidad de vida de 42,3 (DT 12,1) en el componente físico y 41,1 (DT 16,4) en el mental. Percepciones menores sobre la calidad de vida en los dominios estaban principalmente relacionados con enfermedades crónicas, mientras que las mejores percepciones de algunas áreas fueron asociadas con el ocio y tener relación conyugal. Conclusión: Los participantes tuvieron una insatisfactoria calidad de vida. Es necesario el control de enfermedades crónicas, estimulación de hábitos de vida saludables y promoción de salud para mejorar la calidad de vida de estas personas.

Políticas de atenção a idosos na voz de gestores municipais de saúde / Políticas de cuidados a los ancianos en la voz de los gestores municipales de salud / Policies of attention to the elderly according to the voice of the municipal managers of health

Resumo OBJETIVO Analisar o entendimento de gestores municipais de saúde acerca das políticas públicas destinadas a população idosa e a forma de como elas são efetivadas no município. MÉTODO Estudo qualitativo, desenvolvido com 14 gestores municipais de saúde. Os dados foram coletados por meio de entrevista semiestruturada e analisados conforme os preceitos da análise de conteúdo. RESULTADOS Os resultados evidenciam a carência de saberes dos gestores municipais de saúde, relativos a políticas públicas de atenção aos idosos. Também, a atenção prestada a idosos nos municípios estudados centra-se em medidas de controle dos agravos à saúde. CONCLUSÃO Os municípios não possuem políticas específicas de atenção à saúde da população idosa. Assim, estes resultados podem subsidiar reflexões acerca da atenção a idosos nos serviços de saúde, sua relação com a legislação e a aplicabilidade das políticas públicas de saúde.

Resumen OBJETIVO Analizar la comprensión de los gestores municipales de salud acerca de las políticas públicas para la población de ancianos y la forma como ellas entran en vigor en la ciudad. MÉTODO Estudio cualitativo, que se llevó a cabo con 14 gestores municipales de salud. Los datos fueron recogida a través de entrevistas semiestructuradas y analizados de acuerdo con los preceptos de análisis de contenido. RESULTADOS Los resultados muestran una falta de conocimiento de los administradores de salud locales, en relación con la atención política pública para los ancianos. Además, la atención a las personas mayores en los municipios estudiados se centra en las medidas de control de problemas de salud. CONCLUSIÓN Los municipios no tienen cuidado de la salud específica de las políticas de población de edad avanzada. Por lo tanto, estos hallazgos pueden subvencionar reflexiones sobre la atención a las personas mayores en los servicios de salud, su relación con la ley y la aplicación de políticas de salud pública.

Abstract OBJECTIVE To analyze the understanding of municipal managers of health about public policies destined to the elderly population and the way they are effected in the city. METHOD Qualitative study, developed with 14 municipal managers of health. Data were collected through a semi-structured interview and analyzed according the precepts of content analysis. RESULTS The results show the lack of knowledge of the municipal health managers, related to public policies of attention to the elderly. Also, the attention given to the elderly in the studied municipalities focuses on measures to control health problems. CONCLUSION The municipalities do not have specific health care policies for the elderly population. Thus, these results can support reflections about care for the elderly in health services, their relationship with legislation, and the applicability of public health policies.

Organizational and provider level factors in implementation of trauma-informed care after a city-wide training: an explanatory mixed methods assessment.

BACKGROUND: While there is increasing support for training youth-serving providers in trauma-informed care (TIC) as a means of addressing high prevalence of U.S. childhood trauma, we know little about the effects of TIC training on organizational culture and providers' professional quality of life. This mixed-methods study evaluated changes in organizational- and provider-level factors following participation in a citywide TIC training. METHODS: Government workers and nonprofit professionals (N = 90) who participated in a nine-month citywide TIC training completed a survey before and after the training to assess organizational culture and professional quality of life. Survey data were analyzed using multiple regression analyses. A subset of participants (n = 16) was interviewed using a semi-structured format, and themes related to organizational and provider factors were identified using qualitative methods. RESULTS: Analysis of survey data indicated significant improvements in participants' organizational culture and professional satisfaction at training completion. Participants' perceptions of their own burnout and secondary traumatic stress also increased. Four themes emerged from analysis of the interview data, including "Implementation of more flexible, less-punitive policies towards clients," "Adoption of trauma-informed workplace design," "Heightened awareness of own traumatic stress and need for self-care," and "Greater sense of camaraderie and empathy for colleagues." CONCLUSION: Use of a mixed-methods approach provided a nuanced understanding of the impact of TIC training and suggested potential benefits of the training on organizational and provider-level factors associated with implementation of trauma-informed policies and practices. Future trainings should explicitly address organizational factors such as safety climate and morale, managerial support, teamwork climate and collaboration, and individual factors including providers' compassion satisfaction, burnout, and secondary traumatic stress, to better support TIC implementation.

Willingness to pay for National Health Insurance Fund among public servants in Juba City, South Sudan: a contingent evaluation.

BACKGROUND: This study assessed willingness to pay for National Health Insurance Fund (NHIF) among public servants in Juba City. NHIF is the proposed health insurance scheme for South Sudan and aims at achieving universal health coverage for the entire nation's population. One compounding issue is that over the years, governments' spending on healthcare has been decreasing from 8.4% of national budget in 2007 to only 2.2% in 2012. METHODS: A cross-sectional study design using contingent evaluation was employed; data on willingness to pay was collected from 381 randomly selected respondents and 13 purposively selected key informants working for the national, state and Juba County in September 2015. Qualitative data were analysed using conceptual content analysis. T-tests and linear regressions were performed to determine association between WTP for NHIF and independent variables. RESULTS: Up to 381 public servants were interviewed, of which 68% indicated willingness to pay varying percentages of total monthly individual income for NHIF. Over two-thirds (67.8%) of those willing to pay could pay up to 5% of their total monthly income, 22.9% could pay up to 10% and the rest could pay 25%. Over 80% were willing to pay up to 50 SSP (1 USD = 10 SSP) premiums for medical consultation, laboratory services and drugs. The main factors influencing the respondents' decisions were awareness, alternative sources of income, household size, insurance cover and religion. CONCLUSIONS: Willingness to pay is mainly influenced by awareness, alternative sources of individual income, household size, insurance cover and religion. Most of the public servants were aware of and willing to pay for NHIF and prefer a premium of up to 5% of total monthly income. There is need to create awareness and reach out to those who do not know about the scheme in addition to a detailed analysis of other stakeholders. Consideration could be made by the Government of South Sudan to start the scheme at the earliest opportunity since the majority of the respondents were willing to contribute towards it.

The gap between entitlement and access to healthcare: An analysis of "candidacy" in the help-seeking trajectories of asylum seekers in Montreal.

In 2012 the Canadian government made significant cuts to its historically strong federal refugee health coverage plan. While this policy had negligible effects on the level of coverage provided to asylum seekers in Quebec, there is evidence that this group nonetheless experienced reduced healthcare access during the period of polarized national debate that ensued. This study engaged the "candidacy" model of healthcare access to illuminate factors contributing to the observed gap between entitlement and access. Twenty-five semi-structured interviews were conducted with asylum seekers in Montreal to elicit narrative accounts of difficulties encountered in the pursuit of healthcare. Thematic content analysis in conjunction with a holistic examination of help-seeking trajectories revealed several important barriers to obtaining care, including widespread confusion and misinformation about refugee health coverage, cumbersome administrative procedures specific to asylum seekers, and long wait times. Feelings of marginalization and insecurity associated with precarious migratory status appeared to amplify the effects of these barriers to care such that even a minor access difficulty could have dramatic effects on future help-seeking and access outcomes. Demonstrating awareness of public discourses interrogating their deservingness of health coverage, participants often interpreted access difficulties as evidence of health professionals' unwillingness to serve them. Such interpretations conspired with fears associated with the asylum claim process to suppress self-advocacy, further help-seeking, and at times even information-seeking. This finding is particularly significant in that it suggests a mechanism through which hostile public representations of forced migrants-increasingly prevalent in Western host countries-can themselves endanger the physical, psychological, and social health of highly disadvantaged populations, even in the presence of strong entitlement policies. We close with reflections on how theoretical models of healthcare access might be adjusted to better accommodate the unique experiences of precarious status migrants.