Socio-economic inequalities in body mass index among preschool children: do sports programs in early childhood education and care centers make a difference?

Background: Overweight in childhood is considered to be one of the most serious public health challenges. Many studies have investigated individual-level determinants of children's body mass index (BMI), yet studies exploring determinants at the meso-level are sparse. The aim of our study was to examine how a sports focus at early childhood education and care (ECEC) centers moderates the effect of parental socio-economic position (SEP) on children's BMI. Methods: We used data from the German National Educational Panel Study and included 1,891 children (955 boys and 936 girls) from 224 ECEC centers in our analysis. Linear multilevel regressions were used to estimate the main effects of family SEP and the ECEC center sports focus, as well as their interaction, on children's BMI. All analyses were stratified by sex and adjusted for age, migration background, number of siblings, and employment status of parents. Results: Our analysis confirmed the wellknown health inequalities in childhood overweight with a social gradient toward a higher BMI for children from lower SEP families. An interactive effect between family SEP and ECEC center sports focus was found. Boys with low family SEP not attending a sports-focused ECEC center had the highest BMI among all boys. In contrast, boys with low family SEP attending a sports-focused ECEC center had the lowest BMI. For girls, no association regarding ECEC center focus or interactive effects emerged. Girls with a high SEP had the lowest BMI, independent of the ECEC center focus. Conclusion: We provided evidence for the gender-specific relevance of sports-focused ECEC centers for the prevention of overweight. Especially boys from low SEP families benefited from a sports focus, whereas for girls the family's SEP was more relevant. As a consequence, gender differences in determinants for BMI at different levels and their interaction should be considered in further research and preventive measures. Our research indicates that ECEC centers may decrease health inequalities by providing opportunities for physical activity.

Doing primary care integration: a qualitative study of meso-level collaborative practices.

BACKGROUND: The integration of Primary Care (PC) into broader health systems has been a goal in jurisdictions around the world. Efforts to achieve integration at the meso-level have drawn particular attention, but there are few actionable recommendations for how to enact a 'pro-integration culture' amongst government and PC governance bodies. This paper describes pragmatic integration activity undertaken by meso-level participants in Alberta, Canada, and suggests ways this activity may be generalizable to other health systems. METHODS: 11 semi-structured interviews with nine key informants from meso-level organizations were selected from a larger qualitative study examining healthcare policy development and implementation during the COVID-19 pandemic. Selected interviews focused on participants' experiences and efforts to 'do' integration as they responded to Alberta's first wave of the Omicron variant in September 2021. An interpretive descriptive approach was used to identify repeating cycles in the integration context, and pragmatic integration activities. RESULTS: As Omicron arrived in Alberta, integration and relations between meso-level PC and central health system participants were tense, but efforts to improve the situation were successfully made. In this context of cycling relationships, staffing changes made in reaction to exogenous shocks and political pressures were clear influences on integration. However, participants also engaged in specific behaviours that advanced a pro-integration culture. They did so by: signaling value through staffing and resource choices; speaking and enacting personal and group commitments to collaboration; persevering; and practicing bi-directional communication through formal and informal channels. CONCLUSIONS: Achieving PC integration involves not just the reactive work of responding to exogenous factors, but also the proactive work of enacting cultural, relationship, and communication behaviors. These behaviors may support integration regardless of the shocks, staff turnover, and relational freeze-thaw cycles experienced by any health system.

Urban stormwater management at the meso-level: A review of trends, challenges and approaches.

Cities worldwide are facing a significant threat of stormwater hazards caused by the increase in extreme downpours and urbanization. Meso-level urban stormwater management focuses on alleviating the detrimental impacts of urban flooding and enhancing water resource utilization at the block or community scale, typically through 1) specific policies and management rules; 2) catchment-scale scenario simulation, optimization and evaluation; 3) the group of stormwater control measures implementation. It may effectively coordinate macro-level urban stormwater management planning and micro-level distributed stormwater control facilities. This study conducts a review of Urban Stormwater Management at Meso-level (USM-M) with a view to research publication trends, citation analysis, geographic spread and subject category, as well as content analysis, including temporal progression and research gaps. The Web of Science database and CiteSpace are used for the bibliometric analysis of 66 articles from 2006 to 2021. The results show that the number of USM-M topic articles generally has an upward trend over the years. Whilst the United States and China are leading research on this topic, the European countries have diverse local research and dense cooperation. Research foci have generally shifted from theoretical frameworks to multi-element subdivided topics and specific technical roadmaps. Moreover, the spatial layout optimization and multi-functional integration are, or will be, potential research directions in terms of enhancing stormwater utilization and co-benefits of USM-M. This systematic review concludes trends, challenges and potential approaches of USM-M, and aims to provide recommendations for researchers and policymakers on the development of a more advanced and comprehensive USM-M.

Pathways to inclusive and equitable quality early childhood education for achieving SDG4 goal-a scoping review.

According to Sustainable Development Goal 4.2 (SDG 4.2), Equal Access to Quality Pre-primary Education, governments throughout the world are working to ensure that all children have access to high-quality early childhood development, care, and pre-primary education by 2030. In order to organize available evidence into a coherent framework, the current scoping review represents an exploratory synthesis addressing the broad question of what qualitative and inclusive Early Childhood Education and Care strategies are currently being established globally to achieve SDG4 targets. The goal of this scoping review in this respect, was to map the available research and offer an overview of micro-, meso-, and macro-level perspectives on evidence-based interventions and strategies, for the promotion of SDG4 globally. A layered model of early childhood education that is both inclusive and egalitarian education emerged, starting with the micro level: child, family and community, mezo level: nursery, and kindergarten and macro level: national policies and SDG 4.2 Agenda for 2030. The mezzo level connects the micro and macro levels, being the most solicited level of implementing inclusive and qualitative ECEC strategies. Thus, starting with putting a real emphasis on children rights, creating a qualitative and inclusive culture with a holistic understanding of child development, then investing in teacher preparation and instilling a strong belief and positive attitudes toward equity in early childhood services, developing inclusive educational policies with an authentic community support offered by all stakeholders, then adapting curriculum and assessment methods to all early childhood educational contexts and lastly piloting and up-scaling good practices, and investing in infrastructure, facilities and innovative educational services, SDG4.2 targets could transparently and efficiently be attained by 2030, with all the setbacks arisen from the pandemic context. The data provide light on a vast topic range, including human rights and values, policy actions, and ideologies. The micro-level themes emphasized the importance of fostering equitable and inclusive environments for children., as well as instructional approaches that encourage positive attitudes toward diversity and instructors' levels of experience in dealing with diversity. We also discovered the significance of creating chances that promote socialization, connection development, and a sense of belonging. Meso-level principles emphasized the relevance of schooling in a child's holistic development and skill acquisition. Mainstream availability for all children, national curriculum regulations, teacher preparation for inclusive early childhood education, excellent funding and governance, evaluation and monitoring, and research on inclusive early childhood education comprise the macro level. As a concept and an approach, inclusive and qualitative education necessitates the preparedness of all relevant educational components to participate. Providing inclusive education in the early years requires setting the foundation for subsequent levels of schooling. The active engagement of a young kid should be directed by developmentally and individually suitable curricula. Access to and participation in age-appropriate general curricula becomes critical in identifying and providing specialized support services. Inclusive programming does not imply that the educational programs will necessarily be of good quality. Efficiency and wellbeing are synonymous with equity. Equitable education investment benefits everyone in society, not just the most marginalized. Investing in education will help communities achieve all of the Sustainable Development Goals related to education.

Organisation, influence, and impact of patient advisory boards in rehabilitation institutions-an explorative cross-sectional study.

BACKGROUND: Patient participation is highlighted as an important facilitator for patient-centered care. Patient participation organised as patient advisory boards (PABs) is an integral part of health care institutions in Norway. More knowledge is needed on how PAB representatives experience patient engagement (PE) with regard to organisation, influence, and impact. The objective was to describe how PAB representatives experience their tasks, roles, and impact on decision-making processes and service delivery in the setting of rehabilitation institutions. METHODS: PAB representatives recruited from rehabilitation institutions completed the Norwegian version of the generic Public and Patient Engagement evaluation tool (Norwegian abbreviation EBNOR). EBNOR is tested for reliability and validity with good results and comprises 35 items within four main domains, policies and practices, participatory culture, collaboration, and influence and impact that provide responses about PE-levels. The domain items are scored from "strongly disagree" to "strongly agree" on a five-point scale, in addition to a don't know category. Items in the domain "influence and impact" are scored from "never" to "all of the time" on a four-point scale. Categorical data were summarized using frequencies and percentages, and response categories were collapsed into three PE-levels: barrier, intermediate, and facilitating level. Free-text responses were analysed according to principles of manifest content analysis, summed up, and used to elaborate the results of the scores. RESULTS: Of the 150 contacted PAB representatives, 47 (32%) consented to participate. The results showed that approximately 75% agreed that the organisation as a whole was strengthened as a result of patient participation. Four out of five domains were scored indicating a facilitating level; policies and practices (53%), participatory culture (53%), collaboration and common purpose (37%), and final thoughts (63%). The modal score in the domain influence and impact was in the intermediate PE-level (44%). Of a total of 34 codes from free text analyses, barriers to PE were coded 26 times, and PE facilitators were coded 8 times. CONCLUSIONS: The findings indicate that most PAB representatives are satisfied with how rehabilitation institutions organise their PAB, but they still experience their impact as limited.

Associations of individual factors and early childhood education and care (ECEC) centres characteristics with preschoolers' BMI in Germany.

BACKGROUND: The number of obese children is rising worldwide. Many studies have investigated single determinants of children's body mass index (BMI), yet studies measuring determinants at different potential levels of influence are sparse. The aim of this study is to investigate the independent role of parental socioeconomic position (SEP), additional family factors at the micro level, as well as early childhood education and care (ECEC) centre characteristics at the meso level regarding BMI. METHODS: Analyses used the baseline data of the PReschool INtervention Study (PRINS) including up to 1,151 children from 53 ECEC centres. Multi-level models first estimated the associations of parental SEP indicators (parental school education, vocational training, and household income) with the children's standard deviation scores for BMI (SDS BMI, standardised for age and gender). Second, structural (number of siblings), psychosocial (strained family relationships), and nutrition behavioural (soft-drink consumption, frequency of fast-food restaurant visits) family factors at the micro level were included. Third, characteristics of the ECEC centre at the meso level in terms of average group size, the ratio of overweight children in the group, ECEC centre type (all-day care), and the location of the ECEC centre (rural vs urban) were included. All analyses were stratified by gender and adjusted for age, migration background, and parental employment status. RESULTS: Estimates for boys and girls appeared to differ. In the full model, for boys the parental SEP indicators were not related to SDS BMI. Factors related to SDS BMI in boys were: two or more siblings; B = -.55; p = 0.045 [ref.: no sibling]), the characteristics of the ECEC centre in terms of average group size (20 - 25 children; B = -.54; p = 0.022 [ref.: < 20 children]), and the ratio of overweight children (more overweight children B = -1.39; p < 0.001 [ref.: few overweight children]). For girls the number of siblings (two and more siblings; B = .67; p = 0.027 [ref.: no sibling]) and average group size (> 25 children; B = -.52; p = 0.037 [ref.: < 20 children]) were related to SDS BMI. CONCLUSIONS: The BMI of preschool children appears to be associated with determinants at the micro and meso level, however with some gender differences. The identified factors at the micro and meso level appear largely modifiable and can inform about possible interventions to reduce obesity in preschool children.

Meso-level carbon dioxide emission model based on voyage for inland ships in the Yangtze River.

To simplify the micro-level CO2 (carbon dioxide) emission calculation model, reduce the dataset quality requirement of the model, and cut down the volume of calculation, a meso-level voyage-based emission model (MeVEM) for inland ships is proposed with their navigation characteristics considered. The navigation characteristics and the main influencing factors of inland ship emissions are analyzed. The main engine power and average speed of the ships are selected as the model inputs. Accurate CO2 emissions are calculated by the use of the micro-level emission model. With that, first-order and second-order polynomial regression models are employed to establish the fitting formula to estimate the emissions per kilometer. To validate the proposed model, the Junshan segment in the middle reaches of the Yangtze River is selected as the study area, and the model parameters are determined to estimate the CO2 emissions. It is found that the model of emission per kilometer (ej, k) established by second-order polynomial regression is more accurate. The results show that the percentage error in the total amount (PETA) of the results estimated by the four proposed models (CO2 emission estimation model for the upstream cargo ships, the downstream cargo ships, the upstream oil tankers, and the downstream oil tankers) are all within ±5%, which verifies the feasibility and applicability of the model. The proposed meso-level model allows us to use a smaller input dataset which is easier to obtain, and estimate CO2 emissions from ships simply and accurately.

Hotspot identification on urban arterials at the meso level.

Urban arterials form the main structure of city street networks, and typically have high traffic volume and high crash frequency. To reduce the number of crashes, hotspot identification (HSID) is the first step in the traffic safety management process, and often utilizes crash prediction models. Classical crash prediction models investigate the relationship between roadway characteristics and traffic safety at the micro level, that is, they treat road segments and intersections as isolated units. Micro-level analysis has limitations, however, when examining urban arterial crashes: 1) signal spacing is typically short for urban arterials in dense street networks, and there are interactions between intersections and road segments that classical models do not accommodate; and 2) for practical engineering, a hotspot to which countermeasures are applied generally consists of several adjacent intersections and road segments instead of a single intersection or road segment. To address these concerns, signalized intersections and their adjacent road segments were combined into meso-level units, which were adopted to investigate traffic safety data from 21 urban arterials in Shanghai, China. To determine if the meso-level unit is the most suitable research unit for identifying hotspots on urban arterials, and if so, which HSID method can most consistently identify them, this study identified micro-level (separate intersection and road segment) and meso-level (combined intersection and road segment) hotspots using crash frequency, empirical Bayesian (EB), potential for safety improvement (PSI), and full Bayesian (FB) methods. To evaluate the performance of the HSID methods, hotspot consistency over two years was tested. The results showed that 1) EB and PSI performed better than the other methods no matter which research unit was used; 2) substantial inconsistency between the identified micro- and meso-level hotspots. To identify both hazardous corridors and individual intersections and road segments on urban arterials, a combination of micro- and meso-level hotspots should be recommended to local transportation authorities.

Which Meso-Level Characteristics of Early Childhood Education and Care Centers Are Associated with Health, Health Behavior, and Well-Being of Young Children? Findings of a Scoping Review.

Characteristics of early childhood education and care (ECEC) centers might be relevant for children's health. This scoping review aims to provide an overview of the association between meso-level characteristics (MLCs) of ECEC centers with children's health, health behavior, and wellbeing. Five databases were searched for quantitative and qualitative research articles published in English or German since 1 January 2000 on health, health behavior, and wellbeing of children aged 0 to 6 years considering MLCs of ECEC centers. Two authors screened 10,396 potentially eligible manuscripts and identified 117 papers, including 3077 examinations of the association between MLCs and children's health indicators (Kappas > 0.91). Five categories of MLCs were identified: (1) structural characteristics, (2) equipment/furnishings, (3) location, (4) facilities/environment, (5) culture/activities/policies/practices, and 6) staff. Only very few studies found an association of MLCs with body weight/obesity, and general health and wellbeing. Especially physical activity and mental health were related to MLCs. In general, the location (rural vs. urban, neighborhood status) seemed to be a relevant health aspect. MLCs of ECEC centers appeared relevant for child health indicators to different degrees. Future research should focus on these associations, in detail, to identify concrete ECEC indicators that can support health promotion in early childhood.

Meso-level hotspot identification for suburban arterials.

Accurate identification of crash hotspots forms the foundation of roadway safety improvement. The Highway Safety Manual micro-level approach uses individual intersections and road segments as analysis units, and correspondingly identifies some isolated road entities as hotspots. However, because traffic police and administrative agencies routinely conduct safety improvement based on multiple continuous segments and intersections, the identification of hotspots at the micro-level is inefficient for field application. To better meet this need, this study proposes a new meso-level approach to identify hotspots, specifically on suburban arterials. Meso-level analysis units of three different configurations (201, 150, and 100 units) were obtained by combining a set number of intersections and their adjacent segments according to crash distribution and homogeneity. Their influence areas were determined according to the proportion of urbanized land in areas perpendicularly adjacent to the arterials. Three Bayesian Poisson-lognormal conditional autoregressive models (PLN-CAR) considering spatial correlations were developed for each unit configuration, using the full Bayesian (FB) method to ameliorate random fluctuation in crash counts. Potential for safety improvement (PSI) values were calculated based on the modeling results and were used to identify hotspots. Two measures, i.e., the concentrated degree of hotspots (CDH) and the hotspot identification accuracy (HIA), were proposed to make a quantitative and comparative evaluation. Results showed that 1) arterials with more parallel roads suffer lower crash risk, and 2) considering both the hotspot distribution and the identification accuracy, the 150 meso-level unit configuration was the best. The proposed meso-level hotspot identification method promises to be adaptive to safety improvement practices on suburban arterials.

A multilevel hypernetworks approach to capture meso-level synchronisation processes in football.

Understanding team behaviours in sports performance requires understanding the interdependencies established between their levels of complexity (micro-meso-macro). Previously, most studies examined interactions emerging at micro- and macro-levels, thus neglecting those emerging at a meso-level (reveals connections between player and team levels, depicted by the emergence of coordination in specific sub-groups of players-simplices during performance). We addressed this issue using the multilevel hypernetworks approach, adopting a cluster-phase method, to record player-simplice synchronies in two performance conditions where the number, size and location of goals were manipulated (first-condition: 6 × 6 + 4 mini-goals; second-condition: Gk + 6 × 6 + Gk). We investigated meso-level coordination tendencies, as a function of ball-possession (attacking/defending), field-direction (longitudinal/lateral) and teams (Team A/Team B). Generally, large synergistic relations and more stable patterns were observed in the longitudinal direction of the field than the lateral direction for both teams, and for both game phases in the first condition. The second condition displayed higher synchronies and more stable patterns in the lateral direction than the longitudinal plane for both teams, and for both game phases. Results suggest: (i) usefulness of hypernetworks in assessing synchronisation of teams at a meso-level; (ii) coaches may consider manipulating these task constraints to develop levels of local synchronies within teams.

Public Libraries: A Community-Level Resource to Advance Population Health.

Policy makers and public health practitioners rarely consider public libraries to be part of the health system, even though they possess several characteristics that suggest unrealized potential to advance population health. This scoping review uses an adapted social determinants framework to categorize current health-related work conducted by public libraries in the United States and to discuss libraries' potential as 'meso-level' community resources to improve population health. Our discussion of libraries contributes to scholarship on place-based health disparities, by emphasizing the potential impact of institutions that are modifiable through social policy-e.g., parks, community centers, schools-and which have a conceptually clear or empirically documented relationship to health.

Evaluating healthcare priority setting at the meso level: A thematic review of empirical literature.

Background: Decentralization of health systems has made sub-national/regional healthcare systems the backbone of healthcare delivery. These regions are tasked with the difficult responsibility of determining healthcare priorities and resource allocation amidst scarce resources. We aimed to review empirical literature that evaluated priority setting practice at the meso level of health systems. Methods: We systematically searched PubMed, ScienceDirect and Google scholar databases and supplemented these with manual searching for relevant studies, based on the reference list of selected papers. We only included empirical studies that described and evaluated, or those that only evaluated priority setting practice at the meso-level. A total of 16 papers were identified from LMICs and HICs. We analyzed data from the selected papers by thematic review. Results: Few studies used systematic priority setting processes, and all but one were from HICs. Both formal and informal criteria are used in priority-setting, however, informal criteria appear to be more perverse in LMICs compared to HICs. The priority setting process at the meso-level is a top-down approach with minimal involvement of the community. Accountability for reasonableness was the most common evaluative framework as it was used in 12 of the 16 studies. Efficiency, reallocation of resources and options for service delivery redesign were the most common outcome measures used to evaluate priority setting. Limitations: Our study was limited by the fact that there are very few empirical studies that have evaluated priority setting at the meso-level and there is likelihood that we did not capture all the studies. Conclusions: Improving priority setting practices at the meso level is crucial to strengthening health systems. This can be achieved through incorporating and adapting systematic priority setting processes and frameworks to the context where used, and making considerations of both process and outcome measures during priority setting and resource allocation.

Safety analysis of urban arterials at the meso level.

Urban arterials form the main structure of street networks. They typically have multiple lanes, high traffic volume, and high crash frequency. Classical crash prediction models investigate the relationship between arterial characteristics and traffic safety by treating road segments and intersections as isolated units. This micro-level analysis does not work when examining urban arterial crashes because signal spacing is typically short for urban arterials, and there are interactions between intersections and road segments that classical models do not accommodate. Signal spacing also has safety effects on both intersections and road segments that classical models cannot fully account for because they allocate crashes separately to intersections and road segments. In addition, classical models do not consider the impact on arterial safety of the immediately surrounding street network pattern. This study proposes a new modeling methodology that will offer an integrated treatment of intersections and road segments by combining signalized intersections and their adjacent road segments into a single unit based on road geometric design characteristics and operational conditions. These are called meso-level units because they offer an analytical approach between micro and macro. The safety effects of signal spacing and street network pattern were estimated for this study based on 118 meso-level units obtained from 21 urban arterials in Shanghai, and were examined using CAR (conditional auto regressive) models that corrected for spatial correlation among the units within individual arterials. Results showed shorter arterial signal spacing was associated with higher total and PDO (property damage only) crashes, while arterials with a greater number of parallel roads were associated with lower total, PDO, and injury crashes. The findings from this study can be used in the traffic safety planning, design, and management of urban arterials.

Ranking the Meso Level Critical Factors of Electronic Medical Records Adoption Using Fuzzy Topsis Method.

As Electronic Medical Records (EMRs) have a great possibility for rising physician's performance in their daily work which improves quality, safety and efficiency in healthcare, they are implemented throughout the world (Boonstra and Broekhuis, 2010). In physician practices the rate of EMRs adoption has been slow and restricted (around 25%) according to Endsley, Baker, Kershner, and Curtin (2005) in spite of the cost savings through lower administrative costs and medical errors related with EMRs systems. The core objective of this research is to identify, categorize, and analyse meso-level factors introduced by Lau et al, 2012, perceived by physicians to the adoption of EMRs in order to give more knowledge in primary care setting. Finding was extracted through questionnaire which distributed to 350 physicians in primary cares in Malaysia to assess their perception towards EMRs adoption. The findings showed that Physicians had positive perception towards some features related to technology adoption success and emphasized EMRs had helpful impact in their office. The fuzzy TOPSIS physician EMRs adoption model in meso-level developed and its factors and sub-factors discussed in this study which provide making sense of EMRs adoption. The related factors based on meso-level perspective prioritized and ranked by using the fuzzy TOPSIS. The purpose of ranking using these approaches is to inspect which factors are more imperative in EMRs adoption among primary care physicians. The result of performing fuzzy TOPSIS is as a novelty method to identify the critical factors which assist healthcare organizations to inspire their users in accepting of new technology.

Health sector priority setting at meso-level in lower and middle income countries: lessons learned, available options and suggested steps.

Setting priority for health programming and budget allocation is an important issue, but there is little consensus on related processes. It is particularly relevant in low resource settings and at province- and district- or "meso-level", where contextual influences may be greater, information scarce and capacity lower. Although recent changes in disease epidemiology and health financing suggest even greater need to allocate resources effectively, the literature is relatively silent on evidence-based priority-setting in low and middle income countries (LMICs). We conducted a comprehensive review of the peer-reviewed and grey literature on health resource priority-setting in LMICs, focussing on meso-level and the evidence-based priority-setting processes (PSPs) piloted or suggested there. Our objective was to assess PSPs according to whether they have influenced resource allocation and impacted the outcome indicators prioritised. An exhaustive search of the peer-reviewed and grey literature published in the last decade yielded 57 background articles and 75 reports related to priority-setting at meso-level in LMICs. Although proponents of certain PSPs still advocate their use, other experts instead suggest broader elements to guide priority-setting. We conclude that currently no process can be confidently recommended for such settings. We also assessed the common reasons for failure at all levels of priority-setting and concluded further that local authorities should additionally consider contextual and systems limitations likely to prevent a satisfactory process and outcomes, particularly at meso-level. Recent literature proposes a list of related attributes and warning signs, and facilitated our preparation of a simple decision-tree or roadmap to help determine whether or not health systems issues should be improved in parallel to support for needed priority-setting; what elements of the PSP need improving; monitoring, and evaluation. Health priority-setting at meso-level in LMICs can involve common processes, but will often require additional attention to local health systems.

Labor migration, externalities and ethics: theorizing the meso-level determinants of HIV vulnerability.

This paper discusses labor migration as an example of how focusing on the meso-level highlights the social processes through which structural factors produce HIV risk. Situating that argument in relation to existing work on economic organization and HIV risk as well as research on labor migration and HIV vulnerabilities, the paper demonstrates how analyzing the processes through which labor migration creates vulnerability can shift attention away from the proximate behavioral determinants of HIV risk and toward the community and policy levels. Further, it presents the concepts of externalities and the ethics of consumption, which underline how both producers and consumers benefit from low-waged migrant labor, and thus are responsible for the externalization of HIV risk characteristic of supply chains that rely on migrant labor. These concepts point to strategies through which researchers and advocates could press the public and private sectors to improve the conditions in which migrants live and work, with implications for HIV as well as other health outcomes.