What factors shape doctors' trustworthiness? Patients' perspectives in the context of hypertension care in rural Tanzania.

INTRODUCTION: There is increasing evidence that improving patient trust in doctors can improve patients' use of healthcare services, compliance and continuing engagement with care -particularly for chronic diseases. Consequently, much of the current literature on trust in therapeutic relationships focuses on factors shaping doctors' trustworthiness. However, few studies on this issue have been conducted among rural populations in low-income Africa, where health service delivery, cultural norms and patient expectations differ from those in high-income countries. This study examined patients' perspectives of factors that shape doctors' trustworthiness in rural Tanzania in the context of hypertension care. METHODS: A qualitative inquiry using in-depth interviews was conducted between 2015 and 2016 in two characteristically rural districts of Tanzania. Data were analysed thematically. RESULTS: The accounts of 34 patients from a Western-based care setting were examined. There was broad consensus about factors shaping doctors' trustworthiness along the care trajectory (before, during and after a therapeutic encounter). Two major themes emerged: doctors' interpersonal behaviours and doctors' technical competence. Good interpersonal behaviour and technical skills in healthcare settings were factors that constructed a positive reputation in the community and shaped patients' initial trust before a physical encounter. Doctors' interpersonal behaviours that portrayed good customer care, understanding and sympathy shaped trustworthiness during a physical encounter. Finally, doctors' technical competence shaped trustworthiness during and after an encounter. Participants used these factors to differentiate a trustworthy ('good') doctor from an untrustworthy ('bad') doctor. CONCLUSION: Good interpersonal behaviours and good technical skills are important in shaping patients' judgements of doctors' trustworthiness in rural Tanzania. The present findings provide useful insights for designing interventions to improve patient trust in doctors to address challenges associated with non-communicable diseases in rural low-income Africa.

Speculating on health: public health meets finance in 'health impact bonds'.

Where modern public health developed techniques to calculate probability, potentiality, risk and uncertainty, contemporary finance introduces instruments that redeploy these. This article traces possibilities for interrogating the connection between health and financialisation as it is arising in one particular example - the health impact bond. It locates the development of this very recent financial innovation in an account of public health's role within governance strategies over the 20th century to the present. We examine how social impact bonds for chronic disease prevention programmes bring two previously distinct ways of thinking about and addressing risk into the same domain. Exploring the derivative-type properties of health impact bonds elucidates the financial processes of exchange, hedging, bundling and leveraging. As tools for speculation, the functions of health impact bonds can be delinked from any particular outcome for participants in health interventions. How public health techniques for knowing and acting on risks to population health will contest, rework or be subsumed within finance's speculative response to risk, is to be seen.

Beyond resistance: social factors in the general public response to pandemic influenza.

BACKGROUND: Influencing the general public response to pandemics is a public health priority. There is a prevailing view, however, that the general public is resistant to communications on pandemic influenza and that behavioural responses to the 2009/10 H1N1 pandemic were not sufficient. Using qualitative methods, this paper investigates how members of the general public respond to pandemic influenza and the hygiene, social isolation and other measures proposed by public health. Going beyond the commonly deployed notion that the general public is resistant to public health communications, this paper examines how health individualism, gender and real world constraints enable and limit individual action. METHODS: In-depth interviews (n = 57) and focus groups (ten focus groups; 59 individuals) were conducted with community samples in Melbourne, Sydney and Glasgow. Participants were selected according to maximum variation sampling using purposive criteria, including: 1) pregnancy in 2009/2010; 2) chronic illness; 3) aged 70 years and over; 4) no disclosed health problems. Verbatim transcripts were subjected to inductive, thematic analysis. RESULTS: Respondents did not express resistance to public health communications, but gave insight into how they interpreted and implemented guidance. An individualistic approach to pandemic risk predominated. The uptake of hygiene, social isolation and vaccine strategies was constrained by seeing oneself 'at risk' but not 'a risk' to others. Gender norms shape how members of the general public enact hygiene and social isolation. Other challenges pertained to over-reliance on perceived remoteness from risk, expectation of recovery from infection and practical constraints on the uptake of vaccination. CONCLUSIONS: Overall, respondents were engaged with public health advice regarding pandemic influenza, indicating that the idea of public resistance has limited explanatory power. Public communications are endorsed, but challenges persist. Individualistic approaches to pandemic risk inhibit acting for the benefit of others and may deepen divisions in the community according to health status. Public communications on pandemics are mediated by gender norms that may overburden women and limit the action of men. Social research on the public response to pandemics needs to focus on the social structures and real world settings and relationships that shape the action of individuals.

'We had to do what we thought was right at the time': retrospective discourse on the 2009 H1N1 pandemic in the UK.

For a few weeks in 2009 it was not certain whether the world faced a lethal influenza pandemic. As it turned out, the H1N1 pandemic was less severe than anticipated, though the infection did affect groups not usually susceptible to influenza. The deep uncertainties of this pandemic moment were associated with immense practical, scientific and political challenges for public health agencies around the world. We examine these challenges by drawing on the sociology of uncertainty to analyse the accounts given by UK public health practitioners who managed local responses to the pandemic. We discuss the retrospective and mitigating discourse; 'we had to do what we thought was right at the time', used by interviewees to explain their experience of articulating plans for a severe pandemic influenza with one that turned out to be mild. We explore the importance of influenza's history and imagined future for pandemic management and, relatedly, how pandemic response and control plans disrupted the normal ways in which public health exercises its authority. We conclude by suggesting that difficulties in the management of pandemic influenza lie in its particular articulation of precautions, that is, securing a safe future against that which cannot be predicted.

The scope and impact of community participation: The views of community representatives in an Australian health service.

PURPOSE: The purpose of this paper is to examine the views of community representatives participating in a large health service in Australia. DESIGN/METHODOLOGY/APPROACH: Cross-sectional survey of 49 community representatives and interviews with a purposeful sample of representatives (n = 10) and staff (n = 19). FINDINGS: Most community representatives had positive attitudes about their value and potential for influence, citing concrete examples of impact. Having an external network or group was related to their beliefs in their ability to add value to their health service. Community representatives largely agreed they provided a link to, and represented, the wider community although most thought staff did not understand their role or how to work with them. Some staff questioned representativeness of their community representatives. PRACTICAL IMPLICATIONS: Improving community participation is argued to be important in delivering better healthcare services, but effective engagement and representation at the local level is often challenging. Focusing on community representative views takes us beyond debates around representativeness to identify practical strategies to improve practice. The authors recommend health services recruit consumers with strong links to networks in the community, provide a structured and supported program, and improve staff understanding of the range of possible roles for community representatives. Local examples of community representatives' impact on policy and practice should be widely communicated. ORIGINALITY/VALUE: In giving prominence to the views of consumers using triangulated methods, the authors found most could report with clarity what their role was and how they impacted at their local health service.

Between individual agency and structure in HIV prevention: understanding the middle ground of social practice.

When HIV prevention targets risk and vulnerability, it focuses on individual agency and social structures, ignoring the centrality of community in effective HIV prevention. The neoliberal concept of risk assumes individuals are rational agents who act on information provided to them regarding HIV transmission. This individualistic framework does not recognize the communities in which people act and connect. The concept of vulnerability on the other hand acknowledges the social world, but mainly as social barriers that make it difficult for individuals to act. Neither approach to HIV prevention offers understanding of community practices or collective agency, both central to success in HIV prevention to date. Drawing on examples of the social transformation achieved by community action in Australia and Brazil, this article focuses on this middle ground and its role in effective HIV prevention.

Facilitating the action of community representatives in a health service: the role of a community participation coordinator.

BACKGROUND: Commitments to community participation are common in health policy, yet ways to maximise the input and impact of community representatives in health service delivery and care remain elusive, lack empirical evidence and are under-theorised. METHODS: The role of Community Participation (CP) Coordinators involved in an Australian health service were examined in a triangulated multi-method, multi-site ethnographically informed three year study. Formal fieldwork involved observation of just over 42 hours of meetings together with informal interactions in the field with staff and community members and in-depth interviews and discussions with 10 Community Representatives, 19 staff and the seven CP Coordinators employed during the study period. RESULTS: Four key roles that Community Participation Coordinators undertake to support and facilitate the action of community representatives operating within a health service were identified in our analysis: 1) Building skills and confidence; 2) Engaging them in agendas for action: 3) Helping them navigate and understand the health system; and 4) Advocating to staff. A fifth role of advocating externally to outside groups and building coalitions is suggested as important, but was not strongly represented in our data. CONCLUSIONS: This study offers a new model synthesising the key roles of coordinating and facilitating community participation in health services which may be transferable to other health service settings. Our findings call attention to the need for health services to employ a facilitator who can support, engage, navigate and advocate for community representative's participation and influence in health service policy and practice.

Understanding the relationship between the public sector healthcare workers and NGO-based HIV counsellors while providing HIV counselling and testing services to pregnant women: A Qualitative Study in Suva, Fiji.

Human immunodeficiency virus (HIV) counselling and testing plays a significant role in the prevention of mother-to-child transmission of HIV. HIV counselling and testing during pregnancy is an essential gateway for HIV prevention, timely treatment, and care services. Lack of proper counselling could jeopardise the quality of services. This paper aims to understand the relationship between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors while providing HIV counselling and testing services to pregnant women attending antenatal clinic in one of the main hospitals in Suva, Fiji. Data were collected via individual, in-depth, interviews held in a single hospital and an associated reproductive health centre in Suva in April-May 2013. A total of 15 healthcare providers including doctors (n = 4), midwives (n = 5), nurses (n = 4), and counsellors (n = 2) were interviewed. The data were analysed using thematic analysis. Ethical approvals were obtained. We found that there was tension between the government employed hospital healthcare workers and the Non-Governmental Organisation based counsellors involved in the provision of HIV counselling and testing services to pregnant women. The predominant causes of tension were poor referral for HIV test counselling, long counselling time, lack of cooperation and conflict due to the differences in counselling approaches. Tension between the government employed hospital healthcare workers and the Non- Governmental Organisation based HIV counsellors appear to be the main challenge to effective provision of HIV test counselling services in the hospital. Ongoing tension between both groups could restrict healthcare workers abilities to provide quality HIV counselling services. Our findings would be useful in developing strategies to overcome tension amongst healthcare workers as it would be an imperative step in providing streamlined HIV counselling services to women attending antenatal clinic in Fiji.

Beyond the distinction between biomedical and social dimensions of HIV prevention through the lens of a social public health.

Developing effective HIV prevention requires that we move beyond the historical but problematic distinction between biomedical and social dimensions of HIV. The current claim that prevention has failed has led to a strong interest in the role of treatment as HIV prevention; however, the turn to "biomedical prevention," "test and treat," and "combination prevention" instances pervasive confusions about prevention. These confusions arise from a failure to realize that all HIV prevention interventions must engage with the everyday lives of people and be integrated into their social relations and social practices. We challenge the claim that prevention has failed (illustrating this with discussion of prevention in Australia, Uganda, and Zimbabwe). We explain the enduring appeal of misguided approaches to prevention by examining how 1996 can be seen as a pivotal moment in the history of the global response to HIV, a moment marked by the rise and fall of distinct biomedical and social narratives of HIV.

The reach and limits of the US President's Emergency Plan for Aids Relief (PEPFAR) funding of Prevention of Mother-to-Child Transmission (PMTCT) of HIV in Nigeria.

WHO advocates the use of comprehensive 4-pronged strategy for PMTCT of HIV. It includes HIV prevention, preventing unintended pregnancies in HIV positive women and follows up treatment and support as well as therapeutic interventions around delivery. This study examines PEPFAR's funding of Nigerian PMTCT, via an analysis of the funded activities of 396 agencies PEPFAR funds to do PMTCT. PEPFAR Sub-partners selected for this study were included because they were funded to do therapeutic intervention around delivery, but significant gaps were identified regarding the other 3 prongs advocated by WHO. Up to 70% were not funded to do any primary prevention. PEPFAR's own reporting does not allow assessment of Sub-partner involvement in preventing unintended pregnancies. Regarding follow up treatment and care, some Sub-partners were not funded at all. PEPFAR is not supporting a comprehensive approach to PMTCT in the way it funds PMTCT in Nigeria.

Pill testing policy: A comparative analysis using the Advocacy Coalition Framework.

INTRODUCTION: Pill testing is regarded as a controversial harm reduction intervention and provides an ideal case study for examining how policy change comes about. Two Australian jurisdictions were analysed to explore factors that may account for policy change by comparing the ACT which allowed a pill testing trial, and NSW where pill testing has not been permitted. METHODS: The analysis was conducted using the Advocacy Coalition Framework (ACF). Data sources were first coded to establish the subsystem actors beliefs and advocacy coalitions; then coded using a deductive approach and classified against core dimensions of the ACF. An inductive approach was then applied to generate and link themes in the data. RESULTS: A dominant and minority coalition was identified in each jurisdictions' policy subsystem. The results show how in the ACT a dominant 'harm reduction' coalition shifted their secondary beliefs and introduced a pill testing policy. Whereas in NSW, a shift in both the secondary and policy core beliefs of the dominant 'law enforcement' coalition was required, something which rarely occurs according to the ACF. DISCUSSION AND CONCLUSIONS: The analysis supports the ACF's assertion that advocacy coalitions will respond to pressures for change by restricting change to secondary beliefs, while keeping policy core beliefs intact. It also demonstrates that secondary and policy core beliefs matter in the context of minority and dominant coalitions. Further research is needed to explore whether a minority coalition's strategic re-framing of an issue to align with the policy core beliefs of their opponents would have more success than advocating from their own belief paradigm.

Securitising health: Australian newspaper coverage of pandemic influenza.

This paper analyses contemporary Australian newspaper coverage of the threat of pandemic influenza in humans, specifically in the light of recent transformations in biomedical and public health understandings of infectious disease as continuously emerging. Our analysis suggests that the spectre of pandemic influenza is characterised, in newspaper accounts, as invoking a specific form of nation building. The Australian nation is depicted as successfully securing itself in the face of a threat from Asia (and in the absence of an effective international health body). What is described in newspaper accounts reflects a shift in the public health response to infectious disease. This response does not entail a direct focus on protecting either the population or national territory. Instead, it involves the continuous rehearsal of readiness to react to disasters through the networking of government and private agencies responsible for maintaining critical infrastructure. In this way, coverage of pandemic influenza positions health as central to national security, with little reporting of the reasons for or the potential implications of this alliance. Thus, the imperative to 'be prepared' is presented as self-evident.

Living with HIV and negotiating psychological discourse.

Since the introduction of antiretroviral drug treatments, there has been increased interest in the psychological aspects of living with HIV and a growth of related research and therapeutic literature. While there has been concern about the 'remedicalization' of HIV, there is apparently less concern about its 'psychologization'. This article considers how the expansion of psychological discourse about HIV impacts on the lives of HIV-positive people in the era of contemporary treatments. Through analysis of group discussions with HIV-positive gay men, we examine how psychological strategies and terminology are adopted or reworked to cope with the uncertainties of living with HIV. We consider both the enabling and constraining effects of psychological modes of regulation, as they are taken up and reworked by HIV-positive people. Our analysis suggests a need for greater scrutiny of the ways in which psychological techniques are employed as solutions to the ambiguities of living with HIV.

Understanding pandemic influenza behaviour: An exploratory biopsychosocial study.

Pandemic influenza represents an ongoing public health threat. Understanding the associated behavioural domain is vital for future intervention development. Cross-sectional qualitative research employing purposive sampling employed a combination of one-to-one semi-structured interviews (n = 57) and focus groups (n = 59). Data were analysed using (1) inductive thematic analysis and (2) theoretical thematic analysis focusing upon resonance with psychosocial and sociocultural constructs. Two broad themes highlighted an important duality regarding the determinants of pandemic behaviour: (1) psychosocial determinants (e.g. agency, cognitions and identity) and (2) sociocultural determinants (e.g. social context and capacity). These findings suggest this duality should shape future intervention development.

Neglected tropical disease and emerging infectious disease: an analysis of the history, promise and constraints of two worldviews.

Emerging infectious diseases (EIDs) and neglected tropical diseases (NTDs) are medical terms referring to a group of diseases, yet they are simultaneously socio-political constructs (EID and NTD). When viewed as such, public health interest in EID has been criticised as prioritising free market, Global North interests. This paper asks if the recent turn to NTD, which directs attention and resources to 'the bottom billion' of the world's population, addresses the limitations of focusing on EID. Our approach involves comparing the specific socio-political framing, or 'worldview' of NTD, with that of EID. We examine the distinct history, rationales, morals, political and economic tensions and loci of power entailed in each worldview. This analysis suggests that efforts to foreground NTD constitute a site where humanitarian and biomedical industry actors and actions are increasingly blurred. We examine whether the NTD worldview constitutes a break with or a new version of a free market approach to global health, and whether it reworks or solidifies paternalistic Global North-South relations. We consider some of the limits of work on NTD to date, suggesting that although the NTD worldview does not escape the neo-colonial history of global health, it can actualise it under a different form.

Sidestepping questions of legitimacy: how community representatives manoeuvre to effect change in a health service.

Empirical studies of community participation in health services commonly tie effectiveness to the perceived legitimacy of community representatives among health staff. This article examines the underlying assumption that legitimacy is the major pathway to influence for community representatives. It takes a different vantage point from previous research in its examination of data (primarily through 34 in-depth interviews, observation and recording of 26 meetings and other interactions documented in field notes) from a 3-year study of community representatives' action in a large health region in Australia. The analysis primarily deploys Michel de Certeau's ideas of Strategy and Tactic to understand the action and effects of the generally 'weaker players' in the spaces and places dominated by powerful institutions. Through this lens, we can see the points where community representatives are active participants following their own agenda, tactically capitalising on cracks in the armour of the health service to seize opportunities that present themselves in time to effect change. Being able to see community representatives as active producers of change, not simply passengers following the path of the health service, challenges how we view the success of community participation in health.

Mobilising "vulnerability" in the public health response to pandemic influenza.

Analysis of public health's growing interest in "vulnerability" has largely focused on health policy, with little interrogation of how vulnerability is being actively appropriated, countered, ignored or reworked by the publics whose health such policy is designed to protect. Once the assemblage of public health is understood as comprised of different forms of expertise and actors, including publics, addressing this gap matters. We examine the use of vulnerability in the specific context of pandemic influenza preparedness. Pandemic preparedness raises some familiar dilemmas for public health governance: how to engage with publics without fuelling social divisions and disruption; and whether to invoke publics as passive recipients of public health advice or to recognise publics as collective agents responding to the threat of pandemic influenza. Thus, we ask how the mobilisation of vulnerability connects with these dilemmas. To examine vulnerability in pandemic preparedness, two forms of qualitative data are analysed: 1) interviews and focus groups with "vulnerable" and "healthy" people (conducted 2011-12) discussing seasonal and pandemic influenza and; 2) international, Australian national and state level pandemic plans (1999-2013). Vulnerability is variously used in plans as a way to identify groups at particular risk of infection because of pre-existing clinical conditions, and as a free-floating social category that could apply to a broad range of people potentially involved in the social disruption a pandemic might entail. Our interview and focus group data indicate that healthy people rework the free-floating extension of vulnerability, and that people designated vulnerable encounter an absence of any collective responsibility for the threat of pandemic influenza. Our analysis suggests that vulnerability's mobilisation in pandemic preparedness limits the connection between public health governance and its publics: here, the openness and unpredictability of people's collective agency is something to be tightly controlled by a government concerned with protecting people from themselves.