Pandemics, intellectual property and 'our economy': A worldview analysis of Canada's role in compromising global access to COVID-19 vaccines.

Despite self-congratulatory rhetoric, Canada compromised COVID-19 vaccine equity with policies impeding a proposed global waiver of vaccine intellectual property (IP) rules. To learn from Canada's vaccine nationalism we explore the worldview - a coherent textual picture of the world - in a sample of Government of Canada communications regarding global COVID-19 vaccine sharing. Analysed documents portray risks and disparities as unrelated to the dynamics and power relations of the Canadian and international economies. Against this depoliticised backdrop, economic growth fueled by strict IP rules and free trade is advanced as the solution to inequities. Global vaccine access and distribution are pursued via a charity-focused public-private-partnership approach, with proposals to relax international IP rules dismissed as unhelpful. Rather than a puzzling lapse by a good faith 'middle power', Canada's obstruction of global COVID-19 vaccine equity is a logical and deliberate extension of dominant neoliberal economic policy models. Health sector challenges to such models must prioritise equity in global pandemic governance via politically assertive and less conciliatory stances towards national governments and multilateral organisations. Mobilisation for health equity should transform the overall health-damaging macroeconomic model, complementing efforts based on specific individual health determinants or medical technologies.

Reconceptualizing Integrated Knowledge Translation goals: a case study on basic and clinical science investigating the causes and consequences of food allergy.

BACKGROUND: Integrated Knowledge Translation (IKT) and other forms of research co-production are increasingly recognized as valuable approaches to knowledge creation as a way to better facilitate the implementation of scientific findings. However, the nature of some scientific work can preclude direct knowledge to action as a likely outcome. Do IKT approaches have value in such cases? METHODS: This study used a qualitative case study approach to better understand the function of IKT in a non-traditional application: basic and clinical science investigating the causes and consequences of food allergy. Building off previous baseline findings, data were obtained through in-depth interviews with project scientists and steering committee members and complemented by researcher observation. Data were analyzed through an integrated approach to understand how well participants perceived the stipulated project IKT outcomes had been met and to better understand the relationship between different forms of IKT goals, outcomes, and impacts. RESULTS: We propose a conceptual model which builds temporal continuity into the IKT work and understands success beyond truncated timelines of any one project. The model proposes project IKT goals be conceptualized through three metaphorical tower blocks: foundational (changing the culture for both scientists and knowledge-users), laying the groundwork (building relationships, networks and sparking scientific inquiry), and putting scientific knowledge to action. Based on this model, this case study demonstrated notable success at the foundational and intermediate blocks, though did not turn basic and clinical research knowledge into actionable outcomes within the project timespan. CONCLUSIONS: We find that current IKT literature which situates success as filling a knowledge to action gap is conceptually inadequate for understanding the full contributions of IKT activities. This work highlights the need for building cultural and scientific familiarity with IKT in order to better enable knowledge to action translation. Improving understanding and communication of science and empowering knowledge-users to engage with the research agenda are long-term strategies to build towards knowledge implementation and lay the ground work for many future research projects.

Turning the tide on inequity through systematic equity action-analysis.

BACKGROUND: Collective agreement about the importance of centering equity in health research, practice, and policy is growing. Yet, responsibility for advancing equity is often situated as belonging to a vague group of 'others', or delegated to the leadership of 'equity-seeking' or 'equity-deserving' groups who are tasked to lead systems transformation while simultaneously navigating the violence and harms of oppression within those same systems. Equity efforts also often overlook the breadth of equity scholarship. Harnessing the potential of current interests in advancing equity requires systematic, evidence-guided, theoretically rigorous ways for people to embrace their own agency and influence over the systems in which they are situated. ln this article, we introduce and describe the Systematic Equity Action-Analysis (SEA) Framework as a tool that translates equity scholarship and evidence into a structured process that leaders, teams, and communities can use to advance equity in their own settings. METHODS: This framework was derived through a dialogic, critically reflective and scholarly process of integrating methodological insights garnered over years of equity-centred research and practice. Each author, in a variety of ways, brought engaged equity perspectives to the dialogue, bringing practical and lived experience to conversation and writing. Our scholarly dialogue was grounded in critical and relational lenses, and involved synthesis of theory and practice from a broad range of applications and cases. RESULTS: The SEA Framework balances practices of agency, humility, critically reflective dialogue, and systems thinking. The framework guides users through four elements of analysis (worldview, coherence, potential, and accountability) to systematically interrogate how and where equity is integrated in a setting or object of action-analysis. Because equity issues are present in virtually all aspects of society, the kinds of 'things' the framework could be applied to is only limited by the imagination of its users. It can inform retrospective or prospective work, by groups external to a policy or practice setting (e.g., using public documents to assess a research funding policy landscape); or internal to a system, policy, or practice setting (e.g., faculty engaging in a critically reflective examination of equity in the undergraduate program they deliver). CONCLUSIONS: While not a panacea, this unique contribution to the science of health equity equips people to explicitly recognize and interrupt their own entanglements in the intersecting systems of oppression and injustice that produce and uphold inequities.

Changing the culture is a marathon not a sprint.

Integrated knowledge translation (IKT) is built upon the premise that involving knowledge users as partners in the research process will result in science that is more relevant to the public and therefore will have greater impact. Drawing on our experiences with a large and multifaceted IKT food allergy research program we highlight the disjuncture between the goals of IKT and the nature of basic science research, most notably the long timelines before research is ready for translation. Our partner consultations concluded that IKT success should be measured in a different way. That is, it should not be about informing an immediate gap in the translation of food allergy findings but about building relationships between our partners, greater awareness, understanding and knowledge about the nature of science and IKT, and ultimately helping to create better policy and science down the road. It is the recognition that it behooves us as scientists to be able to answer those "why" questions. We call for other researchers to consider the success of IKT beyond the short term timelines of any one research project but instead as an avenue to build partnerships, innovate thinking about research questions and to maximize choice and minimize risk for individuals in Canada and beyond affected by food allergy.

"Exploring knowledge-user experiences in integrated knowledge translation: a biomedical investigation of the causes and consequences of food allergy".

PLAIN ENGLISH SUMMARY: Food allergy is a serious public health problem in Canada and other high-income countries, as it is potentially life threatening and severely impacts the quality of life for individuals and their families. Yet, many questions still remain as to its origins and determinants, and the best practices for treatment. Formed to tackle these very questions, the GET-FACTS research study centers on a novel concept in biomedical research: in order to make this science useful, knowledge creation must include meaningful interactions with knowledge-users. With this, knowledge-users are present at every stage of the research and are crucial, central and equal contributors. This study reflects on the early part of that journey from the perspective of the knowledge-users. We conducted interviews with all non-scientist members of the GET-FACTS steering committee, representing Canadian organizations that deal with patient advocacy and policy with regards to food allergy. Steering committee members had a clear sense that scientists and knowledge-users are equally responsible for putting knowledge into action and the importance of consulting and integrating knowledge-users throughout research. They also have high expectations for the GET-FACTS integrated process; that this model of doing science will create better scientists (e.g. improve communication skills) and make the scientific output more useful and relevant. Our work highlights both the unique contributions that knowledge-users can offer to knowledge creation as well as the challenges of trying to unify members from such different communities (policy/advocacy and biomedical science). There remains a real need to develop more touch points and opportunities for collaboration if true integration is to be achieved. Despite the obstacles, this model can help change the way knowledge is created in the biomedical world. ABSTRACT: ᅟ. BACKGROUND: Despite the burden of food allergic disease many questions remain as to its origins, determinants and best practices for treatment. Formed to tackle these very questions, the GET-FACTS (Genetics, Environment and Therapies: Food Allergy Clinical Tolerance Studies) research study centers around a novel concept in biomedical research: in order to make this science useful, knowledge creation must include meaningful interactions with knowledge-users, known as Integrated Knowledge Translation (IKT). In IKT, knowledge-users are present at every stage of the research and are crucial, central and equal contributors. This paper contributes to this exciting form of research by reflecting on the beginning of that journey from the perspective of the knowledge-users. METHODS: Semi structured in-depth interviews were conducted in year 2 of the 5 year GET-FACTS project with all (n = 9) non-scientist members of the GET-FACTS steering committee, representing Canadian organizations that deal with patient advocacy and policy with regards to food allergy. Transcripts were coded and organized by themes developed both deductively and inductively. RESULTS: Steering committee members indicated a clear sense that scientists and knowledge-users are equally responsible for the translation of knowledge into action and the importance of consulting and integrating knowledge-users throughout research. Overall, these knowledge-users have very high expectations for the GET-FACTS IKT process; they feel that this model of doing science will create better scientists (e.g. improve communication skills) and make the resulting science more useful and relevant; indeed, they reported that this model of knowledge creation can be paradigm shifting. CONCLUSIONS: This study highlights both the unique contributions that knowledge-users can offer to knowledge creation as well as the challenges of trying to unify members from such different communities (policy/advocacy and biomedical science). While our steering committee has a strong conceptual grasp on IKT and vision for their contributions, execution is not without challenges. There remains a real need to develop more touch points and opportunities for collaboration if true integration is to be achieved. Despite the obstacles, the GET-FACTS IKT model represents a new approach to knowledge creation in Canadian biomedical research and can help foster a culture of openness to participant involvement.

"I was on the way to the hospital but delivered in the bush": Maternal health in Ghana's Upper West Region in the context of a traditional birth attendants' ban.

This study examines perceptions and experiences of mothers, traditional birth attendants (TBA), and skilled birth attendants (SBA) regarding Ghana's recent policy that forbids TBAs from undertaking deliveries and restricts their role to referrals. In the larger context of Ghana's highly underdeveloped and geographically uneven health care system, this study draws on the political ecology of health framework to explore the ways global safe motherhood policy discourses intersect with local socio-cultural and political environments of Ghana's Upper West Region (UWR). This study reveals that futile improvements in maternal health and the continued reliance on TBAs illustrate the government's inability to understand local realities marked by poor access to SBAs or modern health care services. Using focus group discussions (FGDs) (n = 10) and in-depth interviews (IDIs) (n = 48) conducted in Ghana's UWR, the findings suggest that mothers generally perceive TBAs as better placed to conduct deliveries in rural isolated communities, where in most cases no SBAs are present or easily accessible. The results indicate that by adhering to the World Health Organization's guidelines, the local government may be imposing detrimental, unintended consequences on maternal and child health in remote rural locations. In addition, the findings suggest that the new policy has resulted in considerable confusion among TBAs, many of whom remain oblivious or have not been officially notified about the new policy. Furthermore, participant accounts suggest that the new policy is seen as contributing to worsening relations and tensions between TBAs and SBAs, a situation that undermines the delivery of maternal health services in the region. The study concludes by suggesting relevant policy recommendations.

"My House Is the Hospital": Housing and Health and Wellbeing among Persons Living with HIV/AIDS in Northern Malawi.

This paper reports findings of a qualitative study and draws on the political ecology of health framework to examine the links between housing and health among people living with HIV/AIDS (PLWAs) in Northern Malawi in a wider context in which the epidemic has overburdened the country's hospitals, thereby transferring the responsibility for care from government to families. The findings suggest that poor housing conditions, rooted in colonial and postcolonial policy failure, may undermine the amount, as well as the quality, of palliative care available to PLWAs. It was also found that the high cost of renting, discrimination, and poor landlord-tenant relationships imposed significant financial and emotional burden on PLWAs, thereby undermining their ability to meet dietary needs, stay healthy, and adhere to treatment. Furthermore, customary norms around property inheritance hampered women's housing security and their ability to cope with the disease. The paper concludes by making relevant policy recommendations.

Can she make it? Transportation barriers to accessing maternal and child health care services in rural Ghana.

BACKGROUND: The Ghana Community based Health Planning and Services (CHPS) strategy targets to bring health services to the doorsteps of clients in a manner that improves maternal and child health outcomes. In this strategy, referral is an important component but it is threatened in a rural context where transportation service is a problem. Few studies have examined perceptions of rural dwellers on transportation challenges in accessing maternal health care services within CHPS. METHODS: Using the political ecology of health framework, this paper investigates transportation barriers in health access in a rural context based on perceived cause, coping mechanisms and strategies for a sustainable transportation system. Eight (8) focus group discussions involving males (n = 40) and females (n = 45) in rural communities in a CHPS zone in the Upper West Region of Ghana were conducted between September and December 2013. RESULTS: Lack of vehicular transport is suppressing the potential positive impact of CHPS on maternal and child health. Consistent neglect of road infrastructural development and endemic poverty in the study area makes provision of alternative transport services for health care difficult. As a result, pregnant women use risky methods such as bicycle/tricycle/motorbikes to access obstetric health care services, and some turn to traditional medicines and traditional birth attendants for maternal health care services. CONCLUSION: These findings underscore the need for policy to address rural transport problems in order to improve maternal health. Community based transport strategy with CHPS is proposed to improve adherence to referral and access to emergency obstetric services.

Is dengue a disease of poverty? A systematic review.

Policy prescriptions for combating dengue fever tend to focus on addressing environmental and social conditions of poverty. However, while poverty has long been considered a determinant of dengue, the research evidence for such a relationship is not well established. Results of a systematic review of the research literature designed to identify and assess the current state of the empirical evidence for the dengue-poverty link reveal a mixed story. Of 260 peer-reviewed articles referencing dengue-poverty relationships, only 12 English-language studies empirically assessed these relationships. Our analysis covering various social and economic conditions of poverty showed no clear associations with dengue rates. While nine of the 12 studies demonstrated some positive associations between measures of dengue and poverty (measured inconsistently through income, education, structural housing condition, overcrowding, and socioeconomic status), nine also presented null results and five with negative results. Of the five studies relating to access to water and sanitation, four reported null associations. Income and physical housing conditions were more consistently correlated with dengue outcomes than other poverty indicators. The small size of this sample, and the heterogeneity of measures and scales used to capture conditions of poverty, make it difficult to assess the strength and consistency of associations between various poverty indicators and dengue outcomes. At present, the global body of eligible English-language peer-reviewed literature investigating dengue-poverty relationships is too small to support a definitive relationship. We conclude that more research, particularly using standardized measures of both outcomes and indicators, is needed to support evidence-informed policies and approaches.

The National Health Insurance Scheme in Ghana's Upper West Region: a gendered perspective of insurance acquisition in a resource-poor setting.

Ghana's National Health Insurance Scheme (NHIS) was designed as a pro-poor strategy to create wider access to health care. While recent studies have shown that wealth is an important factor in enrolment in the scheme, there is little understanding of its interlinkages with the geographical divisions and deep-seated deprivation in the northern region. In response to the nexus of poverty, gender and access to health care, this research took place in Ghana's Upper West Region (UWR), one of the poorest regions and yet paradoxically touting the highest enrolment rates. Using data from a population survey (n = 2119) collected between May to December 2011, we used multinomial regression to examine factors that influence enrolment, controlling for theoretically relevant covariates. Findings reveal that although wealth and desire for health insurance are contributing factors, education was the primary determinant in both never enrolling and in dropping out, and that these factors impact men and women differently. The study also shows that Muslims were less likely to enrol and also women living in non-nuclear households were far more likely to dropout. Our results demonstrate clear gendered divisions in accessing the NHIS, and raised serious equity concerns in the UWR. By focussing on the context of the UWR, we show the importance of understanding intra-household bargaining and resource allocation via the gender dynamics related to health insurance procurement and maintenance, and discuss associated policy implications.

Gendered inequalities within Ghana's National Health Insurance Scheme: are poor women being penalized with a late renewal policy?

This article addresses the implications of the mandatory delay in coverage for individuals residing in the Upper West Region (UWR) of Ghana who have dropped out of the National Health Insurance Scheme (NHIS) but later attempt to reenroll. Using data collected in 2011 in Ghana's UWR, we use a negative log-log model (n=1,584) to compare those who remain enrolled in the scheme with those who have dropped out. Women with unreliable incomes, who reported being food-insecure and those living with young children were more likely to drop out (OR range: 1.22-1.79, p<.05). Men, in contrast, were 50% more likely to drop out of the NHIS for being unsatisfied with services provided (OR range: 1.25-1.62, p<.01). Contrary to the original mandate of the NHIS, our study reveals clear gender differences in the factors contributing to dropouts, pointing to a bias in the impact of the block-out policy that is penalizing women for being poor.

National health insurance scheme enrolment and antenatal care among women in Ghana: is there any relationship?

OBJECTIVES: The objective of this study was to examine whether enrolment in the National Health Insurance Scheme (NHIS) affects the likelihood and timing of utilising antenatal care among women in Ghana. METHODS: Data were drawn from the Ghana Demographic and Health Survey, a nationally representative survey collected in 2008. The study used a cross-sectional design to examine the independent effects of NHIS enrolment on two dependent variables (frequency and timing of antenatal visits) among 1610 Ghanaian women. Negative binomial and logit models were fitted given that count and categorical variables were employed as outcome measures, respectively. RESULTS: Regardless of socio-economic and demographic factors, women enrolled in the NHIS make more antenatal visits compared with those not enrolled; however, there was no statistical association with the timing of the crucial first visit. Women who are educated, living in urban areas and are wealthy were more likely to attend antenatal care than those living in rural areas, uneducated and from poorer households. CONCLUSION: The NHIS should be strengthened and resourced as it may act as an important tool for increasing antenatal care attendance among women in Ghana.

Ghana's National Health Insurance Scheme: a national level investigation of members' perceptions of service provision.

BACKGROUND: Ghana's National Health Insurance Scheme (NHIS), established into law in 2003 and implemented in 2005 as a 'pro-poor' method of health financing, has made great progress in enrolling members of the general population. While many studies have focused on predictors of enrolment this study offers a novel analysis of NHIS members' perceptions of service provision at the national level. METHODS: Using data from the 2008 Ghana Demographic Health Survey we analyzed the perceptions of service provision as indicated by members enrolled in the NHIS at the time of the survey (n = 3468; m = 1422; f = 2046). Ordinal Logistic Regression was applied to examine the relationship between perceptions of service provision and theoretically relevant socioeconomic and demographic variables. RESULTS: Results demonstrate that wealth, gender and ethnicity all play a role in influencing members' perceptions of NHIS service provision, distinctive from its influence on enrolment. Notably, although wealth predicted enrolment in other studies, our study found that compared to the poorest men and uneducated women, wealthy men and educated women were less likely to perceive their service provision as better/same (more likely to report it was worse). Wealth was not an important factor for women, suggesting that household gender dynamics supersede household wealth status in influencing perceptions. As well, when compared to Akan women, women from all other ethnic groups were about half as likely to perceive the service provision to be better/same. CONCLUSIONS: Findings of this study suggest there is an important difference between originally enrolling in the NHIS because one believes it is potentially beneficial, and using the NHIS and perceiving it to be of benefit. We conclude that understanding the nature of this relationship is essential for Ghana's NHIS to ensure its longevity and meet its pro-poor mandate. As national health insurance systems are a relatively new phenomenon in sub-Saharan Africa little is known about their long term viability; understanding user perceptions of service provision is an important piece of that puzzle.

Hepatitis B in Ghana's upper west region: a hidden epidemic in need of national policy attention.

Like many countries in Sub-Saharan Africa, Hepatitis B virus (HBV) is highly prevalent in Ghana. Using qualitative methods, this paper draws from the political ecology of health theoretical framework to examine perceptions and understandings of HBV in the Upper West Region of Ghana. The findings reveal that extremely low levels of knowledge and pervasive lay misconceptions about the disease within this geographic context are shaped by large scale structural influences. Furthermore, in this context there is essentially no access to HBV immunizations, testing or treatment services which reinforces potential routes for the spread of HBV. An explosive spread of HBV is brewing with the potential to diffuse across space and time while, within the institutional contexts, it is the HIV epidemic that is largely consuming both policy attention and intervention.

Circumcision status and time to first sex among never-married young men in Malawi: evidence from the demographic and health survey.

This study examines the association between circumcision status and the timing of first sexual intercourse among adolescents in Malawi. Results of survival models applied to nationally representative sample of never-married young men aged between 15 and 24 obtained from the Demographic and Health Survey data show that being circumcised is associated with earlier initiation of sexual activity in Malawi. Young men who reported being circumcised experienced their first sexual intercourse earlier in life than their uncircumcised counterparts. Although the introduction of theoretically relevant knowledge, socio-cultural, demographic, and socioeconomic variables in the multivariate models attenuated the association between circumcision and earlier sexual initiation, the relationship nonetheless remained robust. The study concludes by discussing the implications of these findings and suggests relevant policy recommendations.