Safety: A collective and embedded competency. An ethnographic study of safety practices at an industrial workplace in the Netherlands.

INTRODUCTION: Organizations place strong emphasis on the standardized occupational health and safety procedures to reduce work-related illnesses and workplace accidents. However, standardized procedures are not always followed up in daily work practices. Organizations must cope with the differences between standardized procedures and local adaptation by employees. METHODS: This ethnographic field study at an industrial workplace in the Netherlands provides insights into employees' everyday work practices, how these work practices are shaped, and how they relate to local occupational health and safety procedures. Acknowledging safety as a competency embedded in work practices, as introduced by Gherardi and Nicolini (2002), offers a theoretical point of view for looking beyond the dichotomy of standardization and local adaptations. RESULTS: The results show that a standardized and noncontextualized occupational health and safety management system that focuses on accident-free days and compliance actually leads to ignorance of practical and tacit competences of workers and no learning and improvement of safety procedures can take place. However, our findings also illustrate how employees in their informal everyday work practices reduce the risks produced by the safety system itself. CONCLUSION: Overall, the results indicate that social interactions among employees, leaders, and management within the organization play an important role in workplace safety. The analysis highlights the value of vulnerability and trust in relationships at work to be able to learn and develop safety procedures that align with local demands. PRACTICAL APPLICATIONS: This study emphasizes the need for participatory approaches in creating safer and healthier workplaces. The cocreation of occupational health and safety (OHS) rules and procedures, however, can only function if they are combined with a responsive leadership style.

(Un)belonging at work: an overlooked ingredient of workplace health.

Organizations offer activities and programmes to improve their employees' health. These workplace health promotion (WHP) activities usually have an individualized and top-down focus, a low uptake among employees, and are perceived to be out of line with employees' experiences and definitions of health. This paper follows up on studies that have broadened the focus of WHP by including social relations and delves deeper into how daily practices and experiences of (un)belonging at work relate to workplace health. Based on ethnographic research in two companies in the Netherlands, this paper analyses how (un)belonging is expressed and experienced by employees. The paper shows that employees define health at work as a social practice. It also demonstrates how dynamics at work shape different dimensions of (un)belonging that, in turn, affect employees' perceived health at work. These findings indicate the importance of including (un)belonging in the workplace as an ingredient of WHP.

Barriers and Facilitators to the Acceptance of eHealth Interventions by Dutch Pediatric Physical Therapists in Times of the COVID-19 Pandemic: A Mixed-Methods Approach.

BACKGROUND: The COVID-19 pandemic created an urgent need for eHealth as the relevance of infection control and social distancing continues. Evidence describing the acceptability of implementing eHealth into pediatric physical therapy services is limited. PURPOSE: To investigate the determinants of eHealth acceptance by Dutch pediatric physical therapists during the COVID-19 pandemic. METHODS: A mixed-methods approach was used. It included a quantitative exploratory questionnaire of 154 pediatric physical therapists and qualitative in-depth interviews of 16 pediatric physical therapists. RESULTS: The eHealth interventions were beneficial for collaboration between health care professionals and in addition to face-to-face therapy. eHealth interventions were, however, found to be unsuitable especially in the diagnostic phase. Barriers to more extensive application include costs, technical difficulties, and a perceived negative attitude of children. CONCLUSION: Pediatric physical therapists used eHealth interventions extensively in times of the COVID-19 pandemic. However, the acceptance of eHealth interventions is dependent on the pediatric physical therapist's perception of usefulness in private practice, rehabilitation setting, or clinical hospital.

Exemplars in Long-Term Care during COVID-19: The Importance of Leadership.

Early in the pandemic, many long-term care (LTC) homes struggled to manage resources and care for vulnerable residents. Using an appreciative inquiry approach, we analyzed exemplar homes in Ontario that remained free of COVID-19 in wave one and interviewed executive directors, directors of care and staff. Findings demonstrate the importance of leadership styles; clear, consistent communication; focusing on staff and resident safety; using a team-based approach; and adapting staff roles to meet care needs. The exemplar homes showed what works in practice. The decisions and approaches that they implemented could be used to develop standards to improve LTC and strengthen the sector.

Perspectives from the Netherlands: Responses from, Strategies of and Challenges for Long-Term Care Health Personnel.

The outbreak of the COVID-19 crisis severely afflicted the Dutch long-term care sector. To protect vulnerable residents of nursing homes the government took several measures, of which the complete nationwide visitors' ban was the most restrictive. These measures had not only a large impact on residents but they also greatly impacted nursing home personnel. Based on a descriptive review and a few interviews, this paper discusses the measures taken in the Dutch long-term care sector and the challenges healthcare personnel encountered in terms of workload and well-being. It further explores the strategies that were implemented to support personnel to cope with these challenges.

A Narrative Review of the Government Wheelchair Provision System in India.

BACKGROUND AND AIM: India has had a wheelchair-delivery system in place for several years but its impact on users is inadequate. Therefore, this research reviews the system to examine how the right to personal mobility can be served better. METHOD: this paper undertakes a narrative review of the existing government-aided wheelchair provision system from the perspectives of legislation and implementing agencies, both governmental and non-governmental, through document review and key informant interviews. RESULTS: the results indicate that all steps of the government-funded wheelchair provision system are executed by the same system. Manufacture and supply take place nationally, but wheelchair services are largely absent. Moreover, the right to access mobility devices is not upheld for all users. CONCLUSION: the established government-aided wheelchair provision system is inadequate in terms of coverage, design, production, supply, and wheelchair services. Therefore, there is a need to reconsider the system by increasing its coverage and creating partnerships between the government, non-governmental agencies, and private agencies to improve access.

The 'exotic other' in medical curricula: Rethinking cultural diversity in course manuals.

Introduction: Implementation of cultural diversity training in medical education faces challenges, including ambiguity about the interpretation of 'cultural diversity'. This is worrisome as research has demonstrated that the interpretation employed matters greatly to practices and people concerned. This study therefore explored the construction of cultural diversity in medical curricula.Methods: Using a constructivist approach we performed a content analysis of course materials of three purposefully selected undergraduate curricula in the Netherlands. Via open coding we looked for text references that identified differences labelled in terms of culture. Iteratively, we developed themes from the text fragments.Results: We identified four mechanisms, showing together that culture is unconsciously constructed as something or someone exotic, deviant from the standard Dutch or Western patient or disease, and therefore problematic.Conclusions: We complemented earlier identified mechanisms of othering and stereotyping by showing how these mechanisms are embedded in educational materials themselves and reinforce each other. We argue that the embedded notion of 'problematic stranger' can lead to a lack of tools for taking appropriate medical action and to insecurity among doctors. This study suggests that integrating more attention to biological and contextual differences in the entire medical curriculum and leaving out static references such as ethnicity and nationality, can enhance quality of medical training and care.

Dark clouds in co-creation, and their silver linings practical challenges we faced in a participatory project in a resource-constrained community in India, and how we overcame (some of) them.

BACKGROUND: While any type of field-based research is challenging, building action-oriented, participatory research in resource-constrained settings can be even more so. OBJECTIVE: In this article, we aim to examine and provide insights into some of the practical challenges that were faced during the course of a participatory project based in two non-notified slums in Bangalore, India, aiming to build solutions to indoor air pollution from cooking on traditional cook stoves. METHODS: The article draws upon experiences of the authors as field researchers engaged in a community-based project that adopted an exploratory, iterative design to its planning and implementation, which involved community visits, semi-structured interviews, prioritization workshops, community forums, photo voice activities, chulha-building sessions and cooking trials. RESULTS: The main obstacles to field work were linked to fostering open, continued dialogue with the community, aimed at bridging the gap between the 'scientific' and the 'local' worlds. Language and cultural barriers led to a reliance on interpreters, which affected both the quality of the interaction as well as the relationship between the researchers and the community that was built out of that interaction. The transience in housing and location of members of the community also led to difficulties in following up on incomplete information. Furthermore, facilitating meaningful participation from the people within the context of restricted resources, differing priorities, and socio-cultural diversity was particularly challenging. These were further compounded by the constraints of time and finances brought on by the embeddedness of the project within institutional frameworks and conventional research requirements of a fixed, pre-planned and externally determined focus, timeline, activities and benchmarks for the project. CONCLUSIONS: This article calls for revisiting of scientific conventions and funding prerequisites, in order to create spaces that support flexible, emergent and adaptive field-based research projects which can respond effectively to the needs and priorities of the community.

Effectiveness of the MetSLIM lifestyle intervention targeting individuals of low socio-economic status and different ethnic origins with elevated waist-to-height ratio.

OBJECTIVE: To evaluate whether the lifestyle intervention MetSLIM targeting individuals of low socio-economic status of Turkish, Moroccan and Dutch origin was successful in improving waist circumference and other cardiometabolic risk factors, lifestyle behaviour and quality of life. DESIGN: A quasi-experimental intervention study (Netherlands Trial Register NTR3721). The intervention group participated in a 12-month combined dietary and physical activity programme. Examinations were performed at baseline and after 12 months. Participants underwent anthropometric measurements and blood withdrawal, and completed questionnaires on dietary intake, physical activity and quality of life. SETTING: Socio-economically deprived neighbourhoods in two Dutch cities, involving non-blinded ethnicity-matched and gender-matched research assistants, dietitians and sports instructors. SUBJECTS: Mainly Turkish (49 %) and Dutch (36 %) subjects, aged 30-70 years, with a waist-to-height ratio of >0·5 (intervention, n 117; control, n 103). Dropout was 31 %. RESULTS: At 12 months, the intervention group showed greater improvements than the control group in waist circumference (ß=-3·3 cm, 95 % CI -4·7, -1·8, P<0·001) and other obesity measures. Additionally, greater reductions were observed for total cholesterol (ß=-0·33 mmol/l, 95 % CI -0·56, -0·10, P=0·005) and LDL cholesterol (ß=-0·35 mmol/l, 95 % CI -0·56, -0·14, P=0·001). Dietary changes were significant for fibre intake (ß=1·5 g/4184 kJ (1000 kcal), 95 % CI 0·3, 2·7, P=0·016). Compared with the control group, the intervention group reported a decrease in total minutes of physical activity (ß=-573 min/week, 95 % CI -1126, -21, P=0·042) and showed improvements in the quality-of-life domains 'health transition' and 'general health'. CONCLUSIONS: MetSLIM was shown to be effective in improving waist circumference, total and LDL cholesterol, and quality of life among Dutch and Turkish individuals living in deprived neighbourhoods.

A lifestyle intervention study targeting individuals with low socioeconomic status of different ethnic origins: important aspects for successful implementation.

BACKGROUND: Evaluation of the implementation process of trials is important, because the way a study is implemented modifies its outcomes. Furthermore, lessons learned during implementation can inform other researchers on factors that play a role when implementing interventions described in research. This study evaluates the implementation of the MetSLIM study, targeting individuals with low socioeconomic status of different ethnic origins. The MetSLIM study was set up to evaluate the effectiveness of a lifestyle programme on waist circumference and other cardio-metabolic risk factors. The objective of this evaluation was to identify components that were essential for the implementation of the MetSLIM study and to inform other researchers on methodological aspects when working with inadequately reached populations in health research. METHODS: In this evaluation study the experiences of health professionals, study assistants, a community worker and regional research coordinators involved in the MetSLIM study were explored using semi-structured interviews. Questionnaires were used to evaluate participants' satisfaction with the lifestyle intervention. RESULTS: Our analyses show that a flexible recruitment protocol eventually leads to recruitment of sufficient participants; that trust in the recruiter is an important factor in the recruitment of individuals with low socioeconomic status of different ethnic origins; and that health professionals will unavoidably shape the form of intervention activities. Furthermore, our evaluation shows that daily practice and research mutually influence each other and that the results of an intervention are a product of this interaction. CONCLUSIONS: Health promotion research would benefit from a perspective that sees intervention activities not as fixed entities but rather as social interaction that can take on numerous forms. Analysing and reporting the implementation process of studies, like in this evaluation, will allow readers to get a detailed view on the appropriateness of the (intended) study design and intervention for the targeted population. Evaluation studies that shed light on the reasons for adaptations, rather than describing them as deviation from the original plan, would point out methodological aspects important for a study's replication. Furthermore, they would show how various factors can influence the implementation, and therewith initiate a learning cycle for the development of future intervention studies. TRIAL REGISTRATION: Netherlands Trial Register NTR3721 (since November 27, 2012).

'Foreigners', 'ethnic minorities', and 'non-Western allochtoons': an analysis of the development of 'ethnicity' in health policy in the Netherlands from 1970 to 2015.

BACKGROUND: The Netherlands, because of the sustained and systematic attention it paid to migrant and minority health issues during the last quarter of the twentieth century, has been depicted as being progressive in its approach to healthcare for migrants and minorities. Recently, however, these progressive policies have changed, reflecting a trend towards problematising issues of integration in order to focus on the responsibilities that migrants and ethnic minorities bear in terms of their health. This article explores these shifts and specifically the development of particular categories of ethnicity, and examines the wider consequences that have arisen as a result. METHODS: The analysis presented here entailed a qualitative content analysis of health policies for migrants and ethnic minorities from 1970 to 2015, and examined various documents and materials produced by the institutions and organisations responsible for implementing these healthcare policies during the period from 1970 to 2015. RESULTS: Four distinct periods of political discourse related to health policy for migrants and ethnic minorities were identified. These periods of political discourse were found to shape the manner in which ethnicity and various categories and representation of foreigners, later ethnic minorities, and at present non-Western allochtoons are constructed in health policy and the implantation practices that follow. At present, in the Netherlands the term allochtoon is used to describe people who are considered of foreign heritage, and its antonym autochtoon is used for those who are considered native to the Netherlands. We discuss the scientific reproduction and even geneticisation of these politically produced categories of autochtoon, Western allochtoon, and non-Western allochtoon-a phenomenon that occurs when politically produced categories are prescribed or taken up by other health sectors. CONCLUSIONS: The categories of autochtoon, Western allochtoon, and non-Western allochtoon in the health sciences and the field of ethnicity and health in the Netherlands today have been co-produced by society and science. Policy formulated on the basis of specific political discourse informs the conceptualisations about groups and categories, issues, and solutions, and when these are institutionalised in subsequent health policy, databases, research, and care practices, these ethnic categorisations are replicated in a manner that renders them 'real' and enables them to be applied both socially and scientifically, culminating in pronouncements as to who is the same and who is different in Dutch society and science.

Ethnicity in Dutch health research: situating scientific practice.

OBJECTIVE: A growing body of work is examining the role health research itself plays in the construction of 'ethnicity.' We discuss the results of our investigation as to how the political, social, and institutional dynamics of the context in which health research takes place affect the manner in which knowledge about ethnicity and health is produced. DESIGN: Qualitative content analysis of academic publications, interviews with biomedical and health researchers, and participant observation at various conferences and scientific events. RESULTS: We identified four aspects related to the context in which Dutch research takes place that we have found relevant to biomedical and health-research practices. Firstly, the 'diversity' and 'inclusion' policies of the major funding institution; secondly, the official Dutch national ethnic registration system; a third factor was the size of the Netherlands and the problem of small sample sizes; and lastly, the need for researchers to use meaningful ethnic categories when publishing in English-language journals. CONCLUSIONS: Our analysis facilitates the understanding of how specific ethnicities are constructed in this field and provides fruitful insight into the socio-scientific co-production of ethnicity, and specifically into the manner in which common-sense ethnic categories and hierarchies are granted scientific validity through academic publication and, are subsequently, used in clinical guidelines and policy.

Responding to Scars After Breast Surgery.

This article represents a phenomenological study on how women endow meaning to their scarred bodies after breast cancer treatment. Data collection consisted of multiple interviews with 10 women who had mastectomy, and 9 women who had breast-saving surgery. Against the background of the phenomenological premise that one's body can appear to oneself in various ways, we identified meaningful differences between experiences that go together with one's body "at a distance" and experiences that go together with one's body's "closeness." The diversity in body experiences we have revealed in our study calls for reconsidering the prejudiced critique of the "body as object" in mainstream phenomenology of health care, and invites medical professionals to develop the ability to recognize different perspectives on embodiment.

Challenges of a healthy lifestyle for socially disadvantaged people of Dutch, Moroccan and Turkish origin in the Netherlands: a focus group study.

Lifestyle interventions often fail to successfully reach individuals with lower socio-economic status (SES), possibly because of the individual behavioural orientation to health behaviour and because limited research has included the target groups' perspectives in the development of interventions. Certainly, in order to make lifestyle interventions more applicable, target groups' viewpoints should to be taken into account. In order to tailor an effective lifestyle intervention to groups with lower SES of different ethnic origins, 14 focus group interviews were conducted with Turkish, Moroccan and Dutch male and female groups. The target groups' responses highlight their viewpoint and their dilemmas with regard to physical activity behaviour and healthy eating. Exploration of the target groups' behaviour in terms of their own logic revealed three prominent themes. Firstly, some individuals find it difficult to maintain healthy eating habits and regular physical activities, as their concept of a healthy life comprises competing values and activities. Secondly, social norms and social practices of others influence health behaviour. Thirdly, respondents' answers reflect how they deal with the dilemma of competing values and norms. They use different ways of reasoning to make sense of their own (health) behaviour. Taken together, the results of this study suggest that considering physical activity and eating as collective social practices rather than as determinants of health will provide new opportunities to initiate healthy lifestyles and to make lifestyle interventions more applicable to target groups' realities.

Policy on professional support in return-to-work: Occupational health professionals' experiences in a Canadian setting.

BACKGROUND: In Canada and other countries, sickness-based absences among workers is an economic and sociological problem. Return-to-work (RTW) policy developed by both employer and worker' representatives (that is, bipartite policy) is preferred to tackle this problem. OBJECTIVE: The intent was to examine how this bipartite agreed-upon RTW policy works from the perspective of occupational health professionals (those who deliver RTW services to workers with temporary or permanent disabilities) in a public healthcare organization in Canada. METHODS: In-depth interviews were held with 9 occupational health professionals and transcribed verbatim. A qualitative, social constructivist, analysis was completed. RESULTS: The occupational health professionals experienced four main problems: 1) timing and content of physicians' medical advice cannot be trusted as a basis for RTW plans; 2) legal status of the plans and thus needing workers' consent and managers' approval can create tension, conflict and delays; 3) limited input and thus little fruitful inference in transdisciplinary meetings at the workplace; and yet 4) the professionals can be called to account for plans. CONCLUSIONS: Bipartite representation in developing RTW policy does not entirely delete bottlenecks in executing the policy. Occupational health professionals should be offered more influence and their professionalism needs to be enhanced.

Adapting an effective lifestyle intervention towards individuals with low socioeconomic status of different ethnic origins: the design of the MetSLIM study.

BACKGROUND: People with low socioeconomic status (SES) and some ethnic minorities are often underrepresented in lifestyle programmes. Therefore, a lifestyle programme was developed especially targeting these groups. Developing this lifestyle programme and designing an intervention study to test the effectiveness of this programme was an informative process in which several obstacles were encountered and choices had to be made. Study protocols, however, rarely describe these obstacles encountered in the protocol design process, and it is not always clear why researchers made certain choices. Therefore, the aim of this article is to describe both the final MetSLIM study protocol and the considerations and choices made in designing this study protocol. METHODS/DESIGN: The developed MetSLIM study has a quasi-experimental design, targeting 30- to 70-year-old adults with an elevated waist circumference, living in deprived neighbourhoods, of Dutch, Turkish or Moroccan descent. The intervention group participates in a 12-month lifestyle programme consisting of individual dietary advice, four group sessions and weekly sports lessons. The control group receives written information about a healthy lifestyle and one group session provided by a dietician. The study contains an elaborate effect, process and economic evaluation. Outcome measures are, among other things, change in waist circumference and the other components of the metabolic syndrome. DISCUSSION: Matching the preferences of the target group, such as their preferred setting, has implications for the entire study protocol. The process evaluation of the MetSLIM study will provide insight into the consequences of the choices made in the MetSLIM study protocol in terms of reach, acceptability and delivery of the programme, and the effect and economic evaluation will provide insight into the (cost)effectiveness of the lifestyle programme in order to reduce waist circumference among individuals with low SES of different ethnic origins. TRIAL REGISTRATION: Netherlands Trial Register NTR3721 (since November 27, 2012).

Perceptions on healthy eating, physical activity and lifestyle advice: opportunities for adapting lifestyle interventions to individuals with low socioeconomic status.

BACKGROUND: Individuals with low socioeconomic status (SES) are generally less well reached through lifestyle interventions than individuals with higher SES. The aim of this study was to identify opportunities for adapting lifestyle interventions in such a way that they are more appealing for individuals with low SES. To this end, the study provides insight into perspectives of groups with different socioeconomic positions regarding their current eating and physical activity behaviour; triggers for lifestyle change; and ways to support lifestyle change. METHODS: Data were gathered in semi-structured focus group interviews among low SES (four groups) and high SES (five groups) adults. The group size varied between four and nine participants. The main themes discussed were perceptions and experiences of healthy eating, physical activity and lifestyle advice. Interviews were transcribed verbatim and a thematic approach was used to analyse the data. RESULTS: In general, three key topics were identified, namely: current lifestyle is logical for participants given their personal situation; lifestyle change is prompted by feedback from their body; and support for lifestyle change should include individually tailored advice and could profit from involving others. The perceptions of the low SES participants were generally comparable to the perceptions shared by the high SES participants. Some perceptions were, however, especially shared in the low SES groups. Low SES participants indicated that their current eating behaviour was sometimes affected by cost concerns. They seemed to be especially motivated to change their lifestyle when they experienced health complaints, but were rather hesitant to change their lifestyle for preventive purposes. Regarding support for lifestyle change, low SES participants preferred to receive advice in a group rather than on their own. For physical activities, groups should preferably consist of persons of the same age, gender or physical condition. CONCLUSIONS: To motivate individuals with low SES to change their lifestyle, it may be useful to (visually) raise their awareness of their current weight or health status. Lifestyle interventions targeting individuals with low SES should take possible cost concerns into account and should harness the supportive effect of (peer) groups.

Ethical considerations of worksite health promotion: an exploration of stakeholders' views.

BACKGROUND: Developing, implementing and evaluating worksite health promotion requires dealing with all stakeholders involved, such as employers, employees, occupational physicians, insurance companies, providers, labour unions and research and knowledge institutes. Although worksite health promotion is becoming more common, empirical research on ethical considerations of worksite health promotion is scarce. METHODS: We explored the views of stakeholders involved in worksite health promotion in focus group discussions and we described the ethical considerations that result from differences between these views. The focus group discussions were organised per stakeholder group. Data were analysed according to the constant comparison method. RESULTS: Our analyses show that although the definition of occupational health is the same for all stakeholders, namely 'being able to perform your job', there seem to be important differences in the views on what constitutes a risk factor to occupational health. According to the employees, risk factors to occupational health are prevailingly job-related. Labour unions agree with them, but other stakeholders, including the employer, particularly see employee-related issues such as lifestyle behaviour as risk factors to occupational health. The difference in definition of occupational health risk factors translates into the same categorisation of worksite health promotion; employee-related activities and work-related activities. The difference in conceptualisation of occupational health risk factors and worksite health promotion resonates in the way stakeholders understand 'responsibility' for lifestyle behaviour. Even though all stakeholders agree on whose responsibility lifestyle behaviour is, namely that of the employee, the meaning of 'responsibility' differs between employees, and employers. For employees, responsibility means autonomy, while for employers and other stakeholders, responsibility equals duty. This difference may in turn contribute to ambivalent relationships between stakeholders. CONCLUSION: All stakeholders, including employees, should be given a voice in developing, implementing and evaluating worksite health promotion. Moreover, since stakeholders agree on lifestyle being the responsibility of the employee, but disagree on what this responsibility means (duty versus autonomy), it is of utmost importance to examine the discourse of stakeholders. This way, ambivalence in relationships between stakeholders could be prevented.

Health in global context; beyond the social determinants of health?

The rise of the social determinants of health (SDH) discourse on the basis of statistical evidence that correlates ill health to SDH and pictures causal pathways in comprehensive theoretical frameworks led to widespread awareness that health and health disparities are the outcome of complex pathways of interconnecting SDH. In this paper we explore whether and how SDH frameworks can be translated to effectively inform particular national health policies. To this end we identified major challenges for this translation followed by reflections on ways to overcome them. Most important challenges affecting adequate translation of these frameworks into concrete policy and intervention are 1) overcoming the inclination to conceptualize SDH as mere barriers to health behavior to be modified by lifestyle interventions by addressing them as structural factors instead; 2) obtaining sufficient in-depth insight in and evidence for the exact nature of the relationship between SDs and health; 3) to adequately translate the general determinants and pathways into explanations for ill health and limited access to health care in local settings; 4) to develop and implement policies and other interventions that are adjusted to those local circumstances. We conclude that to transform generic SDH models into useful policy tools and to prevent them to transform in SDH themselves, in depth understanding of the unique interplay between local, national and global SDH in a local setting, gathered by ethnographic research, is needed to be able to address structural SD in the local setting and decrease health inequity.