European policies for public health in border regions: no European mindset as yet.

BACKGROUND: The sudden emergence of COVID-19 in 2020 demonstrated that Europe was not prepared for a public health crisis like this pandemic. In the European Union, matters of health have remained primarily under the jurisdiction of individual Member States. However, certain events, such as the Kohll-Decker ruling on free mobility of health services and the COVID-19 pandemic, compelled the EU to address health matters in border regions. This study examines how EU policies address public health in border regions. To that end, we have drawn from border studies, a field that provides insight into the fluidity and complexity of borders in everyday life. Besides that we used constructivist policy studies as a lens for the analysis of EU policy documents. METHODS: A policy discourse analysis was conducted to explore how European policy addresses the development of a transnational, European public health in border regions. Key European policy documents published between 2002 and 2027 were analysed to understand how policies are constructed and problems are framed. The analysis was guided by research questions and the theoretical approach. RESULTS: The analysis reveals that, while having limited competences in the field of health care, the EU is slowly developing a rationale and a knowledge base to increase its competences in health care. It also shows that in the field of public health, the EU argues for addressing health determinants and promoting healthy lifestyles, though it does not address health promotion in border regions. The EU's authority in public health in border regions revolves primarily around addressing physical, biological and chemical threats rather than social health problems. CONCLUSION: Though the EU has carefully developed a transnational perspective on health care, the EU has not developed any authority with respect to transnational public health. Though public health and health promotion in border regions have been confronted with specific challenges, neither specific Member States nor the EU have a transnational collaborative perspective that does justice to the characteristics of border regions. When it comes to public health in border regions, there is no European mindset as yet.

Making health public: a philosophy café in a disadvantaged neighbourhood.

Community Based Participatory Research (CBPR) provides important insights in how to mobilize a community for health promotion. This article explores the possibilities for shifting the frame from community to publics for building new forms of public health engagement in disadvantaged neighbourhoods. We present the results of an ethnographic research project on health and resilience in three low-income neighbourhoods in Maastricht, the Netherlands. In the context of a broader University-Citizens collaboration, citizens and researchers organized a monthly philosophy café to discuss subjects related to health and wellbeing. We analyse this in terms of public building and argue that shifting the perspective from community to publics strengthens the emancipatory tradition within CBPR. By creating an open setting, accommodating diversity and disagreements between its participants, the philosophy café constituted a local epistemic public, generating knowledge on health and wellbeing in disadvantaged neighbourhoods.

In this article, we present an analysis of how researchers and citizens in low-income neighbourhoods collaborated to improve health and resilience. Citizens and researchers together organized a monthly philosophy café to discuss subjects related to health and wellbeing. We analyse the philosophy café as the activities of a public rather than a community. The philosophy café was set up as an open setting in which strangers could meet and exchange ideas and experiences. This resulted in lively exchanges and disagreements on what a good life entails. By presenting the philosophy café as a local public, our paper stresses the desire of neighbourhood inhabitants to meet strangers and exchange ideas, rather than to form close attachments to a neighbourhood community.

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

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

Clean Spaces, Community Building, and Urban Stage: the Coproduction of Health and Parks in Low-Income Neighborhoods.

Green zones are potential contributors to health by mitigating disparities between low- and high-income neighborhoods. Against the background of different discourses about city parks-parks as restorative environments, parks as enabling places, and parks as sites for encounters between strangers-we ethnographically studied the coproduction of green spaces and health within low-income neighborhoods. We found three competing notions of urban green, each tied to different notions of neighborhood well-being. Parks as "clean spaces" create expectations of order and peace; parks as places of the community are related to play and activities; and parks as urban stage foster interactions between strangers. By generating experiences that encompass different conceptions of health, citizen-led events can contribute to a shift in the understanding of parks as sites of neighborhood decline to parks as places of hope and new beginnings.

Combining stool and stories: exploring antimicrobial resistance among a longitudinal cohort of international health students.

BACKGROUND: Antimicrobial resistance (AMR) is a global public health concern that requires transdisciplinary and bio-social approaches. Despite the continuous calls for a transdisciplinary understanding of this problem, there is still a lack of such studies. While microbiology generates knowledge about the biomedical nature of bacteria, social science explores various social practices related to the acquisition and spread of these bacteria. However, the two fields remain disconnected in both methodological and conceptual levels. Focusing on the acquisition of multidrug resistance genes, encoding extended-spectrum betalactamases (CTX-M) and carbapenemases (NDM-1) among a travelling population of health students, this article proposes a methodology of 'stool and stories' that combines methods of microbiology and sociology, thus proposing a way forward to a collaborative understanding of AMR. METHODS: A longitudinal study with 64 health students travelling to India was conducted in 2017. The study included multiple-choice questionnaires (n = 64); a collection of faecal swabs before travel (T0, n = 45), in the first week in India (T1, n = 44), the second week in India (T2, n = 41); and semi-structured interviews (n = 11). Stool samples were analysed by a targeted metagenomic approach. Data from semi-structured interviews were analysed using the method of thematic analysis. RESULTS: The incidence of ESBL- and carbapenemase resistance genes significantly increased during travel indicating it as a potential risk; for CTX-M from 11% before travel to 78% during travel and for NDM-1 from 2% before travel to 11% during travel. The data from semi-structured interviews showed that participants considered AMR mainly in relation to individual antibiotic use or its presence in a clinical environment but not to travelling. CONCLUSION: The microbiological analysis confirmed previous research showing that international human mobility is a risk factor for AMR acquisition. However, sociological methods demonstrated that travellers understand AMR primarily as a clinical problem and do not connect it to travelling. These findings indicate an important gap in understanding AMR as a bio-social problem raising a question about the potential effectiveness of biologically driven AMR stewardship programs among travellers. Further development of the 'stool and stories' approach is important for a transdisciplinary basis of AMR stewardship.

Obligatory medical prescription of antibiotics in Russia: Navigating formal and informal health-care infrastructures.

Antimicrobial resistance control programmes often aim to "fix" the behaviour of antibiotic users and prescribers. Such behavioural interventions have been widely criticised in social science literature for being inefficient and too narrow in scope. Drawing on these criticisms, this article analyses how political programmes for fixing antibiotic behaviours were adapted into the practices of health-care professionals and patients in Russia. In 2018, we conducted interviews with medical doctors, pharmacists and patients in a Russian city; focusing on their practices around the policy requirement introduced in 2017 which obligated medical prescriptions of antibiotics. We conceptualised the obligatory medical prescription as a political technique which sought to change practices of self-treatment and over-the-counter sales of medications by establishing doctors as an obligatory passage point to access antibiotics. Our analysis shows that the requirement for medical prescriptions does not fulfil the infrastructural gaps that influence antibiotic practices. By navigating the antibiotic prescriptions, doctors, pharmacists and patients informally compensate for the gaps in the existing infrastructure creating informal networks of antibiotic care parallel to the requirement of obligatory prescriptions. Following these informal practices, we could map the inconsistencies in the current policy approaches to tackle AMR as a behavioural rather than infrastructural problem.

Constructing democratic participation in welfare transitions: An analysis of narrative interactions.

OBJECTIVE: This article provides insights into the democratic character of local enactments of welfare reforms by analysing narrative interactions about changes in care. We analyse processes of storytelling that are part of the interactions between citizens giving, receiving and organizing care and the policymakers governing welfare reforms. We also study how narrative interactions shape understandings about changing care practices and what types of narrative interactions support democracy in care. BACKGROUND: Stories about recent welfare reforms include messages about citizens' care, citizen participation, citizens' powers and revitalization of democracy. However, researchers have cast doubt on their emancipatory and democratic character. RESEARCH SETTING AND METHODOLOGY: We conducted research of four initiatives and municipal policy settings in the city of Maastricht that organized social care in lifeworlds connected to arts, crafts, farming and entrepreneurship during welfare reforms. Using narrative ethnography, we analyse narrative interactions between the master narrative of welfare reforms about 'lifeworld care' and 'citizen powers', and small stories told by participants in new care practices. RESULTS: We identified two types of narrative interaction: idealizing and pragmatizing. Idealizing narrative interactions were strategic for care initiatives in finding support and for policymakers in proving that a so-called 'participation society' works. Pragmatizing narrative interactions gave expression to insights into the everyday practices of social care experiments and included a greater variety of stories. CONCLUSIONS: We conclude that pragmatizing narrative interactions adjust the master narrative about welfare reforms and replace ideals of independency with ideals of active participation in webs of dependency and care.

Experiences of pregnancy in adolescence of internally displaced women in Bogotá: an ethnographic approach.

BACKGROUND: Pregnancy in adolescence is higher among internally displaced women in Colombia than non-displaced women. It is defined as a problem with significant negative outcomes by both biomedical and epidemiological approaches. However, little is known about pregnancy during adolescence from the perspective of women who experienced this in the specific context of armed conflict and displacement. AIM: This article focuses on how internally displaced women understand their experiences of pregnancy in adolescence in the context of armed conflict through an ethnographic approach in a receptor community of internally displaced women in Bogotá, Colombia. METHODS: Based on 10 years of experience in the community, we conducted 1 year of fieldwork, using an ethnographic approach. We collected life stories of 20 internally displaced women through in-depth interviews and ran 8 workshops with them and other women from the community. We used thematic analysis to analyse the responses of internally-displaced women and understand how they made meaning around their experiences of adolescent pregnancy in the context of displacement. RESULTS: The main themes that emerged from participants' experiences include rural violence, early family life (characterized by violence and mistreatment at home), meanings of pregnancy at an early age (including being challenged and feelings of love), and reactions to their pregnancies during adolescence (such as stigmatization) from their families and partners. CONCLUSION: Our analysis of the in-depth interviews and the workshops suggests that adolescent pregnancy among women who are internally displaced has complex dynamics, characterized by the violent context of the rural areas, but primarily by the violence experienced during their childhood. The experience of pregnancy during adolescence brings feelings of ownership and also challenges, together with the forced displacement. This understanding will provide insights for policy makers and healthcare providers on how to work with this specific population who have experienced pregnancy in adolescence.

Collective constructions of 'waste': epistemic practices for disinvestment in the context of Dutch social health insurance.

BACKGROUND: Faced with growing budget pressure, policymakers worldwide recognize the necessity of strategic disinvestment from ineffective, inefficient or harmful medical practices. However, disinvestment programs face substantial social, political and cultural challenges: mistrust, struggles for clinical autonomy or stakeholders' reluctance to engage in what can be perceived as 'rationing'. Academic literature says little about effective strategies to address these challenges. This paper provides insights on this matter. We analyzed the epistemic work of a group of policymakers at the National Health Care Institute on what was initially a disinvestment initiative within the context of the Dutch basic benefits package: the 'Appropriate Care' program. The Institute developed a strategy using national administrative data to identify and tackle low-value care covered from public funds as well as potential underuse, and achieve savings through improved organization of efficiency and quality in health care delivery. How did the Institute deal with the socio-political sensitivities associated with disinvestment by means of their epistemic work? METHOD: We conducted ethnographic research into the National Health Care Institute's epistemic practices. Research entailed document analysis, non-participant observation, in-depth conversations, and interviews with key-informants. RESULTS: The Institute dealt with the socio-political sensitivities associated with disinvestment by democratizing the epistemic practices to identify low-value care, by warranting data analysis by clinical experts, by creating an epistemic safe space for health care professionals who were the object of research into low-value care, and by de-emphasizing the economization measure. Ultimately, this epistemic work facilitated a collaborative construction of problems relating to low-value care practices and their solutions. CONCLUSIONS: This case shows that - apart from the right data and adequate expertise - disinvestment requires clinical leadership and political will on the part of stakeholders. Our analysis of the Institute's Appropriate Care program shows how the epistemic effort to identify low-value care became a co-construction between policymakers, care providers, patients and insurers of problems of 'waste' in Dutch social health insurance. This collective epistemic work gave cognitive, moral and political standing to the idea of 'waste' in public health expenditure.

Challenges in primary care for diabetes and hypertension: an observational study of the Kolar district in rural India.

BACKGROUND: Chronic diseases have emerged as the leading cause of death globally, and 20% of Indians are estimated to suffer from a chronic condition. Care for chronic diseases poses a major public health challenge, especially when health care delivery has been geared traditionally towards acute care. In this study, we aimed to better understand how primary care for diabetes and hypertension is currently organised in first-line health facilities in rural India, and propose evidence-based ways forward for strengthening local health systems to address chronic problems. METHODS: We used qualitative and quantitative methods to gain insight into how care is organised and how patients and providers manage within this delivery system. We conducted in-depth interviews with the medical doctors working in three private clinics and in three public primary health centres. We also interviewed 24 patients with chronic diseases receiving care in the two sub-sectors. Non-participant observations and facility assessments were performed to triangulate the findings from the interviews. RESULTS: The current delivery system has many problems impeding the delivery of quality care for chronic conditions. In both the public and private facilities studied, the care processes are very doctor-centred, with little room for other health centre staff. Doctors face very high workloads, especially in the public sector, jeopardising proper communication with patients and adequate counselling. In addition, the health information system is fragmented and provides little or no support for patient follow-up and self-management. The patient is largely left on their own in trying to make sense of their condition and in finding their way in a complex and scattered health care landscape. CONCLUSIONS: The design and organisation of care for persons with chronic diseases in India needs to be rethought. More space and responsibility should be given to the primary care level, and relatively less to the more specialised hospital level. Furthermore, doctors should consider delegating some of their tasks to other staff in the first-line health facility to significantly reduce their workload and increase time available for communication. The health information system needs to be adapted to better ensure continuity of care and support self-management by patients.

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

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

Engaging cultural resources to promote mental health in Dutch LSES neighborhoods: study of a community-based participatory media project.

Community-based participatory media projects form a promising new strategy for mental health promotion that can help address the mental health-gap identified by the World Health Organization. (2008b) mhGAP, Mental Health Gap Action Programme: Scaling Up Care for Mental, Neurological and Substance Use Disorders. World Health Organization, Geneva. In this article we present an ethnographic study about a participatory media project that was developed to promote mental health in selected Dutch low socio-economic status neighborhoods. Through narrowcastings (group film viewings), participant observation and interviews we mapped the ways in which the media project effected and facilitated the collective sense-making process of the audience with regard to sources of stress impacting mental health and opportunities for action. These determinants of mental health are shaped by cultural dimensions, since the cultural context shapes everyday experiences of stress as well as the resources and skills to manage them. Our analysis shows that the media project engaged cultural resources to challenge stressful social scripts. We conclude that more attention should be paid to cultural narratives in a community to understand how health promotion strategies can support social resilience.

Ethnicity in Dutch health research: situating scientific practice.

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

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

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

Clarifying how social epidemiological research constructs the category of low socioeconomic status: A response to Kamphuis et al.

In our previous article, published in this journal, we argued that epidemiology has a constructive role with regard to socioeconomic health inequalities. We concluded that, as long as the construction of LSES remains unquestioned, social epidemiology might continue to (re)produce what it examines: LSES populations 'known to be unhealthy'. Recently, in this journal, Kamphuis et al. responded to our article. While they welcomed our reflections, the authors also posed critique to our arguments. In this paper, we respond to that critique and deepen the discussion on the use of (L)SES categories in social epidemiology. For this purpose, we further clarify our arguments and state that in health inequality research it is important to: 1) Pay attention to the unintended effects of research; 2) Consider the origin and effects of explanatory concepts; and 3) reflect on the norms of cultural capital.

Patients' work and fluid trajectories: Access to medicines for oncological and rare diseases in Russia.

Health policy studies usually conceptualise access to medicines as a result of the institutional configuration of policies, legislation, and pharmaceutical markets. This study adopts a different approach that stems from the sociology of health and Science and Technology Studies (STS). Based on an ethnographically inspired qualitative research of access practices of patients with oncological and rare diseases in Russia, we argue that access to medicines is a fluid and unstable trajectory constructed by the everyday practices of patients. Instead of seeing patients as passive recipients of institutionally arranged access, we focus on their practices of building access and identify four types of work they do to steer their access trajectories in the desired direction. These types of work include persisting work, complying work, adjusting work, and knowing work. In many studies of access, these types of work remain invisible, and thus the efforts and skills that patients need to make access possible remain unnoticed, undervalued, and unaccounted for.

The 'empowered client' in vocational rehabilitation: the excluding impact of inclusive strategies.

In vocational rehabilitation, empowerment is understood as the notion that people should make an active, autonomous choice to find their way back to the labour process. Following this line of reasoning, the concept of empowerment implicitly points to a specific kind of activation strategy, namely labour participation. This activation approach has received criticism for being paternalistic, disciplining and having a one-sided orientation on labour participation. Although we share this theoretical criticism, we want to go beyond it by paying attention to the practical consequences of understanding empowerment as an activation strategy. Inspired by the field of Science and Technology Studies, we will explore the meaning of empowerment and activation in concrete practices of vocational rehabilitation in the Netherlands. Our analysis is based on the narratives of people with a work disability about their lives and the vocational rehabilitation programmes they participated in. We present five illustrative cases that how empowerment is 'done' in the practice of vocational rehabilitation and its unintended effects. Our analysis demonstrates that activation strategies seem to be caught in a paradox: instead of including people in society, they have excluding consequences. Vocational rehabilitation professionals can go beyond this paradox by learning from the ways in which empowerment is 'done' by clients in vocational rehabilitation programmes.

Overcoming the tragedy of urban commons. Collective practices for a healthy city ecology in disadvantaged neighborhoods.

This paper provides insight into collective practices for promoting a healthy city ecology in disadvantaged neighborhoods. Using ethnography, we analyze the actions of a citizen collective to improve a park as 'urban commoning' and 'placemaking.' The analysis shows that first, the collective received ambivalent bureaucratic support; second, the open character of space commons enabled collective responsibility and democratic publics, but also made them vulnerable; and third, in providing informal security, the collective restrained itself to avoid stigma and retaliation. We conclude that open commons enable collective responsibility, but in disadvantaged city areas, they suffer from ongoing bureaucratic governance and accumulations of adversity.

A Look at Cycling Safety in a Southern Municipality of the Netherlands.

Objectives Cycling is an important means of transportation in the Netherlands. Unfortunately, the number of cycling accidents and their adverse outcomes (injury and death) are on the rise. We set out to observe the nature of these accidents in Maastricht from 2001 to 2015 and analyzed the recommendations of stakeholders on ways to improve cycling safety. Methods An explanatory sequential mixed methodology was used for this population-based study. In the first phase, a retrospective quantitative analysis of the VIA® accident database for Maastricht was done. This was followed by a thematic analysis of data from five semi-structured interviews. Integration was at the Interpretation stage. Result The first phase showed males (54%) and under-25s (59.9%) had the most cycling accidents, while a larger percentage of females (50.7%) and people >65 years (67%) had adverse outcomes with accidents. More accidents occurred at intersections (52.6%), on shared roads (61.4%), and involved motorized vehicles (95.6%). Bivariate analysis and multivariable logistic regression showed that cycling accidents involving elderly people, women, wet weather or road surfaces, an innocent cyclist, the northeastern district, and morning hours had a higher chance of injury or death. Thematic analysis summarised stakeholder opinions under four themes: role in cycling safety; partners of cycling safety; the importance of accurate data; and investing in safety. Most of the respondents felt improvements in the city's accident database, cycling policy, and infrastructure were needed. Conclusion Our findings suggest that there has been a decrease in the overall number of cycling accidents in the 15-year period studied. However, differences in sociodemographic variables still determine the distribution and severity of accidents in Maastricht. The existing cycling database at the time of the study needed improvements with data collection and the city needs to involve more stakeholders in its policy-making process.