Predictors of COVID-19 vaccine acceptability among refugees and other migrant populations: A systematic scoping review.

OBJECTIVE: This study aimed to map the existing literature to identify predictors of COVID-19 vaccine acceptability among refugees, immigrants, and other migrant populations. METHODS: A systematic search of Medline, Embase, Scopus, APA PsycInfo and Cumulative Index of Nursing and Allied Health Literature (CINAHL) was conducted up to 31 January 2023 to identify the relevant English peer-reviewed observational studies. Two independent reviewers screened abstracts, selected studies, and extracted data. RESULTS: We identified 34 cross-sectional studies, primarily conducted in high income countries (76%). Lower vaccine acceptance was associated with mistrust in the host countries' government and healthcare system, concerns about the safety and effectiveness of COVID-19 vaccines, limited knowledge of COVID-19 infection and vaccines, lower COVID-19 risk perception, and lower integration level in the host country. Female gender, younger age, lower education level, and being single were associated with lower vaccine acceptance in most studies. Additionally, sources of information about COVID-19 and vaccines and previous history of COVID-19 infection, also influence vaccine acceptance. Vaccine acceptability towards COVID-19 booster doses and various vaccine brands were not adequately studied. CONCLUSIONS: Vaccine hesitancy and a lack of trust in COVID-19 vaccines have become significant public health concerns within migrant populations. These findings may help in providing information for current and future vaccine outreach strategies among migrant populations.

Linking weather and health outcomes: Examining the potential influences of weather factors and particulate matter pollution on adverse pregnancy outcomes in the Kavre district, Nepal.

INTRODUCTION: Adverse pregnancy outcomes (APOs) include stillbirth, preterm birth, and low birthweight (LBW). Studies exploring the impact of weather factors and air pollution on APOs are scarce in Nepal. We examined the impacts of prenatal exposure to temperature, precipitation, and air pollution (PM2.5) on APOs among women living in Kavre, Nepal. METHODS: We conducted a hospital and rural health centers-based historical cohort study that included health facility birth records (n = 1716) from the Nepali fiscal year 2017/18 through 2019/20. We linked health records to temperature, precipitation, and PM2.5 data for Kavre for the six months preceding each birth. A random intercept model was used to analyze birthweight, while a composite APO variable, was analyzed using multivariable logistic regression in relation to environmental exposures. RESULTS: The proportion of LBW (<2500 gm), preterm birth (babies born alive before 37 weeks of gestation), and stillbirth was 13%, 4.3%, and 1.5%, respectively, in this study. Overall, around 16% of the study participants had one or more APOs. Total precipitation (ß: 0.17, 95% CI 0.01 to 0.33, p = 0.03) had a positive effect on birthweight in the wetter season. Negative effects for mean maximum (ß: 33.37, 95% CI -56.68 to -10.06, p = 0.005), mean (ß: 32.35, 95% CI -54.44 to -10.27, p = 0.004), and mean minimum temperature (ß: 29.28, 95% CI -49.58 to -8.98, p = 0.005) on birthweight was also observed in the wetter season. CONCLUSION: A positive effect of temperature (mean maximum, mean, and mean minimum) and total precipitation on birthweight was found in the wetter season. This study emphasizes the need for future research using larger cohorts to elucidate these complex relationships in Nepal.

Vaccines for all: A formative evaluation of a multistakeholder community-engaged COVID-19 vaccine outreach clinic for migrant communities.

Background: Racialized, low-income, and migrant populations experience persistent barriers to vaccines against COVID-19. These communities in East and Northeast Calgary were disproportionately impacted by COVID-19, yet faced vaccine access barriers. Diverse multi-stakeholder coalitions and community partnerships can improve vaccine outreach strategies, but how stakeholders perceive these models is unknown. Methods: We conducted a formative evaluation of a low-barrier, community-engaged vaccine outreach clinic in Calgary, Alberta, Canada, on June 5-6, 2021. We delivered an online post-clinic survey to clinic stakeholders, to assess whether the clinic achieved its collectively derived pre-specified goals (effective, efficient, patient-centered, and safe), to asses whether the clinic model was scalable, and to solicit improvement recommendations. Survey responses were analyzed using descriptive statistics and thematic analysis. Results: Overall, 166/195 (85%) stakeholders responded. The majority were from non-healthcare positions (59%), between 30 and 49 years of age (87/136; 64%), and self-identified as racialized individuals (96/136; 71%). Respondents felt the clinic was effective (99.2%), efficient (96.9%), patient-centered (92.3%), and safe (90.8%), and that the outreach model was scalable 94.6% (123/130). There were no differences across stakeholder categories. The open-ended survey responses supported the scale responses. Improvement suggestions describe increased time for clinic planning and promotion, more multilingual staff, and further efforts to reduce accessibility barriers, such as priority check-in for people with disabilities. Conclusion: Diverse stakeholders almost universally felt that this community-engaged COVID-19 vaccine outreach clinic achieved its goals and was scalable. These findings support the value of community-engaged outreach to improve vaccine equity among other marginalized newcomer communities.

Globalization and the health and well-being of migrant domestic workers in Malaysia.

BACKGROUND: Neoliberal globalization contributes to the out-migration of labour from sending countries in the global South. Supported by multilateral organizations including the IMF and World Bank, the migration and development nexus holds that nations and households in migrant sending countries can migrate their way out of poverty. Two countries that embrace this paradigm, the Philippines and Indonesia, are major suppliers of migrant labour including domestic workers, and Malaysia is a primary destination country. THEORY AND METHODS: We deployed a multi-scalar and intersectional lens to highlight the impact of global forces and policies, interacting with constructions of gender and national identity, to explore the health and wellbeing of migrant domestic workers in Malaysia. In addition to documentary analysis, we conducted face-to-face interviews with 30 Indonesian and 24 Filipino migrant domestic workers, five representatives from civil society organizations, three government representatives, and four individuals engaged in labour brokerage and the health screening of migrant workers in Kuala Lumpur. RESULTS: Migrant domestic workers in Malaysia work long hours in private homes and are not protected by labour laws. Workers were generally satisfied with their access to health services; however, their intersectional status, which is both an outcome of, and contextualized by, the lack of opportunities in their own country, prolonged familial separation, low wages, and lack of control in the workplace, contributed to stress and related disorders-which we regard as the embodied manifestation of their migratory experiences. Migrant domestic workers eased these ill effects through self-care, spiritual practices, and the embrace of gendered values of self-sacrifice for the family as a form of solace. CONCLUSIONS: Structural inequities and the mobilization of gendered values of self-abnegation underpin the migration of domestic workers as a development strategy. While individual self-care practices were used to cope with the hardships of their work and family separation, these efforts did not remedy the harms nor redress structural inequities wrought by neoliberal globalization. Improvements in the long-term health and wellbeing of Indonesian and Filipino migrant domestic workers in Malaysia cannot focus solely on the preparation and maintenance of healthy bodies for productive labour, but must attend to workers' attainment of adequate social determinants of health, which challenges the migration as development paradigm. Neo-liberal policy instruments such as privatization, marketisation and commercialization of migrant labour have led to both host and home countries benefitting, but at the expense of the migrant domestic workers' well-being.

Complexities of health and care worker migration pathways and corresponding international reporting requirements.

The increasing complexity of the migration pathways of health and care workers is a critical consideration in the reporting requirements of international agreements designed to address their impacts. There are inherent challenges across these different agreements including reporting functions that are misaligned across different data collection tools, variable capacity of country respondents, and a lack of transparency or accountability in the reporting process. Moreover, reporting processes often neglect to recognize the broader intersectional gendered and racialized political economy of health and care worker migration. We argue for a more coordinated approach to the various international reporting requirements and processes that involve building capacity within countries to report on their domestic situation in response to these codes and conventions, and internationally to make such reporting result in more than simply the sum of their responses, but to reflect cross-national and transnational interactions and relationships. These strategies would better enable policy interventions along migration pathways that would more accurately recognize the growing complexity of health worker migration leading to more effective responses to mitigate its negative effects for migrants, source, destination, and transit countries. While recognizing the multiple layers of complexity, we nevertheless reaffirm the fact that countries still have an ethical responsibility to undertake health workforce planning in their countries that does not overly rely on the recruitment of migrant health and care workers.

Hiding in plain sight: the absence of consideration of the gendered dimensions in 'source' country perspectives on health worker migration.

BACKGROUND: Gender roles and relations affect both the drivers and experiences of health worker migration, yet policy responses rarely consider these gender dimensions. This lack of explicit attention from source country perspectives can lead to inadequate policy responses. METHODS: A Canadian-led research team partnered with co-investigators in the Philippines, South Africa, and India to examine the causes, consequences and policy responses to the international migration of health workers from these 'source' countries. Multiple-methods combined an initial documentary analysis, interviews and surveys with health workers and country-based stakeholders. We undertook an explicit gender-based analysis highlighting the gender-related influences and implications that emerged from the published literature and policy documents from the decade 2005 to 2015; in-depth interviews with 117 stakeholders; and surveys conducted with 3580 health workers. RESULTS: The documentary analysis of health worker emigration from South Africa, India and the Philippines reveal that gender can mediate access to and participation in health worker training, employment, and ultimately migration. Our analysis of survey data from nurses, physicians and other health workers in South Africa, India and the Philippines and interviews with policy stakeholders, however, reveals a curious absence of how gender might mediate health worker migration. Stereotypical views were evident amongst stakeholders; for example, in South Africa female health workers were described as "preferred" for "innate" personal characteristics and cultural reasons, and in India men are directed away from nursing roles particularly because they are considered only for women. The finding that inadequate remuneration was as a key migration driver amongst survey respondents in India and the Philippines, where nurses predominated in our sample, was not necessarily linked to underlying gender-based pay inequity. The documentary data suggest that migration may improve social status of female nurses, but it may also expose them to deskilling, as a result of the intersecting racism and sexism experienced in destination countries. Regardless of these underlying influences in migration decision-making, gender is rarely considered either as an important contextual influence or analytic category in the policy responses. CONCLUSION: An explicit gender-based analysis of health worker emigration, which may help to emphasize important equity considerations, could offer useful insights for the health and social policy responses adopted by source countries.

Understanding Social Network and Support for Older Immigrants in Ontario, Canada: Protocol for a Mixed-Methods Study.

BACKGROUND: Older adults are the fastest growing age group worldwide and in Canada. Immigrants represent a significant proportion of older Canadians. Social isolation is common among older adults and has many negative consequences, including limited community and civic participation, increased income insecurity, and increased risk of elder abuse. Additional factors such as the social, cultural, and economic changes that accompany migration, language differences, racism, and ageism heighten older immigrants' vulnerability to social isolation. OBJECTIVE: This mixed-methods sequential (qualitative-quantitative) study seeks to clarify older immigrants' social needs, networks, and support and how these shape their capacity, resilience, and independence in aging well in Ontario. METHODS: Theoretically, our research is informed by an intersectionality perspective and an ecological model, allowing us to critically examine the complexity surrounding multiple dimensions of social identity (eg, gender and immigration) and how these interrelate at the micro (individual and family), meso (community), and macro (societal) levels in diverse geographical settings. Methodologically, the project is guided by a collaborative, community-based, mixed-methods approach to engaging a range of stakeholders in Toronto, Ottawa, Waterloo, and London in generating knowledge. The 4 settings were strategically chosen for their diversity in the level of urbanization, size of community, and the number of immigrants and immigrant-serving organizations. Interviews will be conducted in Arabic, Mandarin, and Spanish with older women, older men, family members, community leaders, and service providers. The study protocol has received ethics approval from the 4 participating universities. RESULTS: Quantitative and qualitative data collection is ongoing. The project is funded by the Social Sciences and Humanities Council of Canada. CONCLUSIONS: Comparative analyses of qualitative and quantitative data within and across sites will provide insights about common and unique factors that contribute to the well-being of older immigrants in different regions of Ontario. Given the comprehensive approach to incorporating local knowledge and expert contributions from multilevel stakeholders, the empirical and theoretical findings will be highly relevant to our community partners, help facilitate practice change, and improve the well-being of older men and women in immigrant communities. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12616.

Thai women's experiences of and responses to domestic violence.

PURPOSE: Domestic violence has been linked to many health consequences. It can impact women's mental, physical, sexual, and reproductive health, and all of these effects can be long lasting. Despite the growing awareness of the deleterious effects of domestic violence in Thailand, there have been few nation-wide studies that have examined the issue and its consequences. In fact, Thailand has not examined intimate partner violence incidence for the past 20 years. This study aimed to investigate the consequences of domestic violence across the country. SUBJECTS AND METHODS: A cross-sectional study was conducted in four areas of Thailand: central, southern, northern, and northeastern. One province in each area was selected by simple random sampling techniques. One thousand four hundred and forty-four married or cohabiting females in a heterosexual union, aged 20-59 years, were included in the sample and were interviewed about their experiences of psychological, physical, and sexual violence by their male partners. RESULTS: One thousand four hundred and forty-four women completed the interviews. Sixteen percent of respondents encountered domestic violence in its various psychological, physical, or sexual forms. In the majority of cases, all forms of domestic violence were exerted repeatedly. Four-fifths of women who faced domestic violence reported that it had an impact on their physical and mental health as well as employment. This study also found that half of the domestic violence survivors reported their children had witnessed violent situations. These women exercised four coping strategies to deal with their domestic violence: 1) counseling; 2) requesting help from others; 3) fighting back; and 4) running away from home. CONCLUSION: The findings confirm that domestic violence has implications that extend beyond health and result in the deterioration of the quality of women's lives. These results underscore that domestic violence is a serious problem that must be addressed in Thai society.

An examination of the causes, consequences, and policy responses to the migration of highly trained health personnel from the Philippines: the high cost of living/leaving-a mixed method study.

BACKGROUND: Dramatic increases in the migration of human resources for health (HRH) from developing countries like the Philippines can have consequences on the sustainability of health systems. In this paper, we trace the outflows of HRH from the Philippines, map out its key causes and consequences, and identify relevant policy responses. METHODS: This mixed method study employed a decentered, comparative approach that involved three phases: (a) a scoping review on health workers' migration of relevant policy documents and academic literature on health workers' migration from the Philippines; and primary data collection with (b) 37 key stakeholders and (c) household surveys with seven doctors, 329 nurses, 66 midwives, and 18 physical therapists. RESULTS: Filipino health worker migration is best understood within the context of macro-, meso-, and micro-level factors that are situated within the political, economic, and historical/colonial legacy of the country. Underfunding of the health system and un- or underemployment were push factors for migration, as were concerns for security in the Philippines, the ability to practice to full scope or to have opportunities for career advancement. The migration of health workers has both negative and positive consequences for the Philippine health system and its health workers. Stakeholders focused on issues such as on brain drain, gain, and circulation, and on opportunities for knowledge and technology transfer. Concomitantly, migration has resulted in the loss of investment in human capital. The gap in the supply of health workers has affected the quality of care delivered, especially in rural areas. The opening of overseas opportunities has commercialized health education, compromised its quality, and stripped the country of skilled learning facilitators. The social cost of migration has affected émigrés and their families. At the household level, migration has engendered increased consumerism and materialism and fostered dependency on overseas remittances. Addressing these gaps requires time and resources. At the same time, migration is, however, seen by some as an opportunity for professional growth and enhancement, and as a window for drafting more effective national and inter-country policy responses to HRH mobility. CONCLUSIONS: Unless socioeconomic conditions are improved and health professionals are provided with better incentives, staying in the Philippines will not be a viable option. The massive expansion in education and training designed specifically for outmigration creates a domestic supply of health workers who cannot be absorbed by a system that is underfunded. This results in a paradox of underservice, especially in rural and remote areas, at the same time as underemployment and outmigration. Policy responses to this paradox have not yet been appropriately aligned to capture the multilayered and complex nature of these intersecting phenomena.

Cultural influences on palliative family caregiving: service recommendations specific to the Vietnamese in Canada.

BACKGROUND: Much of what is known about family caregiving at end-of-life in Canada has been studied within the context of various disease categories or across different care settings, rather than in relation to specific ethnic/cultural identities. Such homogeneity belies the impact of cultural and social factors on the experiences and outcomes of palliative and end-of-life (P/EOL) care. We know little about the end-of-life experiences of Vietnamese-Canadian families. Consequently, there is a lack of understanding around how to best meet the needs of Vietnamese care recipients, caregivers, and their families via the health service system, whose services of which we know they have limited access. RESULTS: To determine a set of service recommendations for health care settings (including the home) specific to caring for Vietnamese (P/EOL) care recipients, caregivers and their families, a qualitative instrumental case-study design was employed. The perspectives of 18 adult Vietnamese family caregivers (FCGs) were obtained. In addition, seven semi-structured key informant interviews were implemented with a range of personnel from community service providers to front-line health care professionals. The ways in which caregiving was perceived and expressed were reflected in three thematic findings: (1) Natural: identity and care work; (2) Intentional: whole person care; and (3) Intensive: standards, struggle, and the context of care. Ten main recommendations have been vetted with service provider leaders and confirmed as being appropriate for uptake. CONCLUSIONS: The ten service recommendations for health care settings (including the home), if implemented, would contribute to improved P/EOL services for the Vietnamese population. Further research involves the evaluation of these policy and programs.

Globalization and the health of Canadians: 'Having a job is the most important thing'.

BACKGROUND: Globalization describes processes of greater integration of the world economy through increased flows of goods, services, capital and people. Globalization has undergone significant transformation since the 1970s, entrenching neoliberal economics as the dominant model of global market integration. Although this transformation has generated some health gains, since the 1990s it has also increased health disparities. METHODS: As part of a larger project examining how contemporary globalization was affecting the health of Canadians, we undertook semi-structured interviews with 147 families living in low-income neighbourhoods in Canada's three largest cities (Montreal, Toronto and Vancouver). Many of the families were recent immigrants, which was another focus of the study. Drawing on research syntheses undertaken by the Globalization Knowledge Network of the World Health Organization's Commission on Social Determinants of Health, we examined respondents' experiences of three globalization-related pathways known to influence health: labour markets (and the rise of precarious employment), housing markets (speculative investments and affordability) and social protection measures (changes in scope and redistributive aspects of social spending and taxation). Interviews took place between April 2009 and November 2011. RESULTS: Families experienced an erosion of labour markets (employment) attributed to outsourcing, discrimination in employment experienced by new immigrants, increased precarious employment, and high levels of stress and poor mental health; costly and poor quality housing, especially for new immigrants; and, despite evidence of declining social protection spending, appreciation for state-provided benefits, notably for new immigrants arriving as refugees. Job insecurity was the greatest worry for respondents and their families. Questions concerning the impact of these experiences on health and living standards produced mixed results, with a majority expressing greater difficulty 'making ends meet,' some experiencing deterioration in health and yet many also reporting improved living standards. We speculate on reasons for these counter-intuitive results. CONCLUSIONS: Current trends in the three globalization-related pathways in Canada are likely to worsen the health of families similar to those who participated in our study.

Impacts of a Support Intervention for Zimbabwean and Sudanese Refugee Parents: "I Am Not Alone".

Knowledge about the beneficial effects of social support has not been used to systematically develop and evaluate interventions to help refugee new parents cope. The purpose of this study was to design and evaluate a social support intervention for refugee new parents. A multi-method research design was used and participatory research strategies were employed. Qualitative and quantitative measures were used to understand experiences of participants and to assess the perceived psychosocial and health-related outcomes of the intervention. Mentored support groups, matched by gender and ethnicity, met biweekly over 7 months. The participants were 48 Sudanese and 37 Zimbabwean refugee parents in 2 Canadian provinces. Increases were found in informational support, spousal support, community engagement, coping, and support-seeking. Decreases were found in parenting stress, loneliness, and isolation. The authors conclude that there is a need for culturally appropriate nursing practices and programs for refugee new parents from diverse cultures.

Les connaissances concernant les effets bénéfiques du soutien social n'ont pas été utilisées de manière systématique pour élaborer et évaluer les interventions visant à aider les réfugiés nouveaux parents à s'adapter à leur situation. L'objectif de cette étude est de concevoir et d'évaluer une intervention pour venir en aide aux réfugiés nouveaux parents. Diverses méthodes de recherche et différentes stratégies de recherche participative ont été utilisées pour la réalisation de l'étude. Des mesures quantitatives et qualitatives ont été effectuées pour comprendre l'expérience vécue par les participants et pour évaluer les résultats perçus de l'intervention sur les plans psychologique et de la santé. Des groupes de soutien encadrés et formés en fonction du sexe et de l'ethnie se sont réunis toutes les deux semaines pendant sept mois. L'ensemble des nouveaux parents participants comprenait 48 réfugiés soudanais et 37 réfugiés zimbabwéens établis dans deux provinces canadiennes. Ces groupes ont donné lieu à un accroissement du soutien informationnel, du soutien conjugal, de la participation communautaire, de l'adaptation et des demandes d'aide, ainsi qu'à une diminution du stress, de la solitude et de l'isolement des parents. En conclusion de leur étude, les auteurs signalent la nécessité d'adopter des programmes et des pratiques de soins infirmiers adaptés sur le plan culturel aux besoins des réfugiés nouveaux parents appartenant à diverses cultures.

Migrant beer promoters' experiences accessing reproductive health care in Cambodia, Laos, Thailand, and Vietnam: lessons for planners and providers.

Migrant beer promoters in Cambodia, Laos, Thailand, and Vietnam were surveyed to determine their experiences in accessing reproductive health care services in the cities of Phnom Penh, Vientiane, Bangkok, and Hanoi. A total of 7 health care institutions were chosen as popular with migrant beer promoters. Staff at these institutions provided information on the institution, and 390 beer promoters were surveyed about their experiences while accessing services. There were discrepancies between findings from the staff interviews and the experiences of the beer promoters. In general, the migrant women were satisfied with the cost, location, friendliness of the health care providers, and knowledge and skills of the providers. They were less positive about confidentiality and waiting times, though many still agreed that these were not an issue. Health care planners and providers should take note of the issues affecting access to reproductive health care services for migrant women when they design and implement services.

Improving health equity: the promising role of community health workers in Canada.

This article reports findings from an applied case study of collaboration between a community-based organization staffed by community health workers/multicultural health brokers (CHWs/MCHBs) serving immigrants and refugees and a local public health unit in Alberta, Canada. In this study, we explored the challenges, successes and unrealized potential of CHWs/MCHBs in facilitating culturally responsive access to healthcare and other social services for new immigrants and refugees. We suggest that health equity for marginalized populations such as new immigrants and refugees could be improved by increasing the role of CHWs in population health programs in Canada. Furthermore, we propose that recognition by health and social care agencies and institutions of CHWs/MCHBs, and the role they play in such programs, has the potential to transform the way we deliver healthcare services and address health equity challenges. Such recognition would also benefit CHWs and the populations they serve.

Kenyan nurses involvement in national policy development processes.

The aim of this study was to critically examine how nurses have been involved in national policy processes in the Kenyan health sector. The paper reports qualitative results from a larger mixed method study. National nonnursing decision-makers and nurse leaders, and provincial managers as well as frontline nurse managers from two Kenyan districts were purposefully selected for interviews. Interviews dealt with nurses' involvement in national policy processes, factors hindering nurses' engagement in policy processes, and ways to enhance nurses' involvement in policy processes. Critical theory and feminist perspectives guided the study process. Content analysis of data was conducted. Findings revealed that nurses' involvement in policy processes in Kenya was limited. Only a few nurse leaders were involved in national policy committees as a result of their positions in the sector. Critical analysis of the findings revealed that hierarchies and structural factors as well as nursing professional issues were the primary barriers constraining nurses' involvement in policy processes. Thus, there is need to address these factors both by nurses themselves and by nonnursing decision makers, in order to enhance nurses engagement in policy making and further the contribution to quality of services to the communities.

Community health workers in Canada: innovative approaches to health promotion outreach and community development among immigrant and refugee populations.

This article provides results from an empirical case study that showcases a community health worker practice targeting immigrants and refugees in Canada. The study focuses on the Multicultural Health Brokers practice, which offers an innovative approach to health promotion outreach and community development addressing broad social determinants of health. This article offers new evidence of both the role of community health worker interventions in Canada and community health workers as an invisible health and human services workforce. It also discusses the Multicultural Health Brokers contribution both to the "new public health" vision in Canada and to a practice that fosters feminist urban citizenship.

Facilitators and barriers to accessing reproductive health care for migrant beer promoters in Cambodia, Laos, Thailand and Vietnam: a mixed methods study.

BACKGROUND: The purpose of the research was to assess access to sexual and reproductive health services for migrant women who work as beer promoters. This mixed methods research was conducted in Phnom Penh, Cambodia, Bangkok, Thailand, Vientiane, Laos, and Hanoi, Vietnam during 2010 to 2011. METHODS: Focus groups were held with beer promoters and separate focus groups or interviews with key informants to explore the factors affecting beer promoters' access to health care institutions for reproductive health care. The findings of the focus groups were used to develop a survey for beer promoters. This survey was conducted in popular health institutions for these women in each of the four Asian cities. RESULTS: Several common themes were evident. Work demands prevented beer promoters from accessing health care. Institutional factors affecting care included cost, location, environmental factors (e.g. waiting times, cleanliness and confidentiality) and service factors (e.g. staff attitudes, clinic hours, and availability of medications). Personal factors affecting access were shyness and fear, lack of knowledge, and support from family and friends.The survey of the beer promoters confirmed that cost, location and both environmental and service factors impact on access to health care services for beer promoters. Many beer promoters are sexually active, and a significant proportion of those surveyed rely on sex work to supplement their income. Many also drink with their clients. Despite a few differences amongst the surveyed population, the findings were remarkably similar across the four research sites. CONCLUSIONS: Recommendations from the research include the provision of evening and weekend clinic hours to facilitate access, free or low cost clinics, and health insurance through employer or government plans which are easy to access for migrants. Other improvements that would facilitate the access of beer promoters to these services include increased funding to hire more staff (reducing waiting times) and to stock more needed medications, mobile clinics to come to the workplace or free transportation for beer promoters to the clinics, improved training to reduce health care provider stigma against beer promoters, and public education about the importance of reproductive health care, including preventative services.

Working with, working through: Towards equitable partnerships in health research

Feminist researchers advocate a more equitable relationship between the researcher and the researched. While qualitative researchers generally eschew hierarchical language reflected in phrases such as, "working on research subjects," in favor of phrasing that denotes partnership, as in "working with research participants," it is unclear as to whether these changes in language have been effectively translated into changes in working relationships. In this paper, I examine how feminist research and researchers illuminate the benefits of developing more equitable partnerships in health research. I suggest that although the challenges are plentiful, our efforts to work through them collectively, enables us to produce better and more meaningful health research.