Navigating whiteness: affective relational intensities of non-clinical psychosocial support by and for culturally and linguistically diverse people.

Mental health is political, with intersecting economic, cultural, racialized, and affective dimensions making up the care assemblage, signalling how care is conceptualised and who is deserving of care. In this article, we examine emotions circulating in a non-clinical psychosocial support program for culturally and linguistically diverse people experiencing mental ill-health, foregrounding the relations between culture, race, economy, and assumptions underpinning understandings of care. The mental health program under study offers psychosocial support for culturally and linguistically diverse people to manage life challenges and mental ill-health exacerbated by navigating the complexities of Australia's health and social care systems. We draw on interviews with clients, staff, and providers of intersecting services, employing Ahmed's concept of affective economies and Savreemootoo's concept of navigating whiteness to examine the care assemblage within interview transcripts. We provide insight into affective intensities such as hate, anger, and indifference embedded in white Anglo-centric services, positioning culturally and linguistically diverse people on the margins of care. Non-clinical psychosocial support programs can counter such affective intensities by training and employing multicultural peer support workers-people with lived experience-prioritising relational and place-based approaches to care and supporting and providing clients with relevant skills to navigate an Anglo-centric care system. However, this support is filled with affective tensions: (com)passion, frustration and fatigue circulate and clash due to the scarcity of resources, further signalling what type of care (and with/for whom) is prioritised within Australian relations of care.

Distress in the care of people with chronic low back pain: insights from an ethnographic study.

Introduction: Distress is part of the experiences and care for people with chronic low back pain. However, distress is often pathologised and individualised; it is seen as a problem within the individual in pain and something to be downplayed, avoided, or fixed. To that end, we situate distress as a normal everyday relational experience circulating, affecting, moving in, through, and across bodies. Challenging practices that may amplify distress, we draw on the theorisation of affect as a relational assemblage to analyse physiotherapy clinical encounters in the care of people with chronic low back pain. Methods: Adopting a critical reflexive ethnographic approach, we analyse data from a qualitative project involving 15 ethnographic observations of patient-physiotherapist interactions and 6 collaborative dialogues between researchers and physiotherapists. We foreground conceptualisations of distress- and what they make (im)possible-to trace embodied assemblage formations and relationality when caring for people with chronic low back pain. Results: Our findings indicate that conceptualisation matters to the clinical entanglement, particularly how distress is recognised and navigated. Our study highlights how distress is both a lived experience and an affective relation-that both the physiotherapist and people with chronic low back pain experience distress and can be affected by and affect each other within clinical encounters. Discussion: Situated at the intersection of health sociology, sociology of emotions, and physiotherapy, our study offers a worked example of applying an affective assemblage theoretical framework to understanding emotionally imbued clinical interactions. Viewing physiotherapy care through an affective assemblage lens allows for recognising that life, pain, and distress are emerging, always in flux. Such an approach recognises that clinicians and patients experience distress; they are affected by and affect each other. It demands a more humanistic approach to care and helps move towards reconnecting the inseparable in clinical practice-emotion and reason, body and mind, carer and cared for.

Staying safe, feeling welcome, being seen: How spatio-temporal configurations affect relations of care at an inclusive health and wellness centre.

BACKGROUND: People experiencing homelessness also experience poorer health and frequently attend acute care settings when primary health care would be better equipped to meet their needs. Existing scholarship identifies a complex mix of individual and structural-level factors affecting primary health care engagement driving this pattern of health services utilisation. We build on this existing knowledge, by bringing the spatio-temporal configurations of primary health care into focus. Specifically, we interrogate how space and time inflect situated practices and relations of care. METHODS: This study took an ethnographic approach and was conducted 2021-2022 at an inclusive health and wellness centre ("the Centre") in Southeast Queensland, Australia. The data consists of 46 interviews with 48 people with lived experience of homelessness, including participants who use the services offered at the Centre (n = 26) and participants who do not (n = 19). We also interviewed 20 clinical and non-clinical service providers affiliated with the Centre and observed how service delivery took place. Interviews and observations were complemented by visual data, including participant-produced photography. All data were analysed employing a narrative framework. RESULTS: We present three interrelated themes demonstrating how space and time affect care, that is 'staying safe', 'feeling welcome' and 'being seen'. 'Staying safe' captures the perceptions and practices around safety, which sit in tension with making service users feel welcome. 'Feeling welcome' attends to the sense of being invited to use services free of judgment. 'Being seen' depicts capacities to see a health care provider as well as being understood in one's lived experience. CONCLUSION: Spatio-temporal configurations, such as attendance policies, consultation modalities and time allocated to care encounters afford differential opportunities to nurture reciprocal relations. We conclude that flexible service configurations can leverage a relational model of care. PATIENT OR PUBLIC CONTRIBUTION: Service providers were consulted during the design stage of the project and had opportunities to inform data collection instruments. Two service providers contributed to the manuscript as co-authors. People with lived experience of homelessness who use the services at the inclusive health centre contributed as research participants and provided input into the dissemination of findings. The photography they produced has been featured in an in-person exhibition, to which some have contributed as consultants or curators. It is hoped that their insights into experiences of welcomeness, safety and being seen will inform flexible and relational primary health care design, delivery, and evaluation to better cater for people experiencing housing instability and poverty.

Increases in income-support payments reduce the demand for charity: A difference-in-difference analysis of charitable-assistance data from Australia over the COVID-19 pandemic.

Charities play an increasingly important role in helping people experiencing poverty. However, institutionalized charity shifts the burden of poverty reduction away from the state and exposes recipients to stress and stigma. In this paper, we examine whether the need for institutionalized charity can be offset through enhanced state support. As in other countries, the Australian government responded to the COVID-19 pandemic by substantially increasing the level of income support to citizens through several temporary payments. We draw on this natural experiment and time-series data from the two largest charity organizations in Queensland, Australia to examine how these payments altered the demand for institutionalized charity. We model these data using difference-in-difference regression models to approximate causal effects. By exploiting the timing and varying amounts of the payments, our analyses yield evidence that more generous income support reduces reliance on charity. Halving the demand for charity requires raising pre-pandemic income-support by AUD$42/day, with supplements of approximately AUD$18/day yielding the greatest return on investment.

Of Good Mothers and Violent Fathers: Negotiating Child Protection Interventions in Abusive Relationships.

This article examines the efficacy of a supportive housing program aiming to provide mothers in violent relationships with the practical resources to minimize child protection intervention. Drawing on qualitative interviews with program mothers, child safety officers, and program practitioners, we explore the extent to which the program enabled mothers and children to live free from fathers' violence and disengage from the child protection system. We find that, although valuable, the program did not fully mitigate the risks posed by violent fathers. We therefore argue that responsibility must be shifted onto violent fathers to change their behavior and build their parenting capacities.

Connection, connectivity and choice: Learning during COVID-19 restrictions across mainstream schools and Flexible Learning Programmes in Australia.

The COVID-19 pandemic and associated school closures may have constrained educational participation particularly for students in disadvantaged circumstances. We explore how 30 disadvantaged students in secondary school (14 mainstream/16 Flexible Learning Programme) from Queensland, New South Wales and Tasmania experienced home learning during the first wave of COVID-19, teasing out nuances across two educational models. Drawing on semi-structured interviews with these students, our analysis revealed three interconnected themes inflecting their learning: connection, connectivity and choice. Connection captures the desire for belonging and practices that facilitated meeting this desire during system-wide disruptions to school routines and face-to-face learning. Connectivity captures the impact of digitally facilitated learning at home on students' ability to engage with curriculum content and with their learning community. Choice captures the availability of viable options to overcome barriers students encountered in their learning and possibilities to flexibly accommodate student preferences and learning needs. Students from Flexible Learning Programmes appeared generally better supported to exercise agency within the scope of their lived experience of home-based learning. Findings indicate a need for strengthening student-centred policy and practices aimed at leveraging the affordances of information technology, balancing self-directed and structured learning and providing holistic support to enable meaningful student choice.

Reconfiguring time: optimisation and authenticity in accounts of people surviving with advanced cancer.

Increasingly, people live longer with advanced cancer, despite having no prospect of full recovery. Ongoing survival is owed to early detection and effective disease management, yet experienced as highly precarious. In this article we explore how cancer chronicity brings into effect a pre-occupation with time, what time is to people with advanced cancer, and what socio-cultural norms inflect everyday practices. We analyse 20 interviews conducted in Queensland, Australia with 11 participants with advanced cancer, to trace the intersections of what time means, what people do with time, and what time feels like. Drawing on scholarship on the moralities around ill health, we discuss how awareness of time emerges in cancer chronicity and raises moral questions on how to live well. Here, imperatives of optimisation (urging people with advanced cancer to make the most of limited time) intersect with imperatives of authenticity (marked by emphasis on how to live one's own best life). These dynamics reveal expressions of living with advanced cancer in morally viable ways. Such ontological processes have implications for the lived experience of people with advanced cancer, their families and oncological care.

Surprise Reveals the Affective-Moral Economies in Cancer Illness Narratives.

Emotions, like joy and sorrow, feature in illness narratives, dramatizing stories of becoming: sick, well, controlled, in control. However, brief emotions, such as surprise, have received limited analytic attention in cancer illness narratives. Drawing on 20 interviews with 11 participants with diverse cancer diagnoses, along with the 455 photographs they produced for this study, we address the complex interactions between discourse, societal expectations, and perceptions in moral-affective economies. Tracing the emergence, deployment, and silencing of surprise provided an avenue to explore connections between affect, morality, advocacy, and philanthropy. We show how surprise works to deny uncertainties couched in individual risk, and situate cancer causation within the logics of anticipation, (re)producing socio-cultural etiology narratives. Attending to surprise reveals how some cancers are situated as individual responsibilities, with restricted access to compassion and collective resources. Thus, we interrogate the affective-moral economy underpinning cancer illness narratives, and surprise's pivotal role in its analysis.

Deploying Normality: Cancer Survivor Identity and Authenticity in Ritual-like Practice.

In scholarship on cancer survivorship, "normality" is discussed as a strategy to restore and maintain continuity of identity for the person with cancer. I interrogate the strategic deployment of "normality" in what I define as ritual-like practices by drawing on 20 narrative interviews and 455 photographs produced by study participants. The findings explore normality as outcome (being normal), practice (doing normality), and ethical standard (aspiring to normality). They indicate how sociocultural scripts such as the cancer survivor identity and authentic selfhood inflect what it means to be a "normal" person with cancer with repercussions for recognition in lived experience.

Cancer survivorship reimagined: A qualitative study on evolving interpretative repertoires of cancer and survivorship using participant-produced photography.

OBJECTIVE: As more people live with cancer and for longer time periods, it is important to understand the growing diversity in lived experiences of survivorship. This study explored interpretative repertoires around cancer and their implications for survivorship from the perspectives of people with cancer to inform communication in cancer care. METHODS: The sample included 11 participants (7 male, 4 female) with diverse cancer diagnoses and prognoses recruited through two public cancer care centres in Queensland, Australia. A narrative analysis of sequential interviews (n = 20) and photographs produced by the participants (n = 455) was conducted. RESULTS: Four interrelated metaphors and narratives emerged in the interpretative repertoires of participants: cancer as a presence, survivorship as a struggle for meaning, survivorship as movement and survivorship as confluence. Continuities with "battle" and "journey" terminology were evident. However, these were subtly adapted and reimagined within participants' own lived experience. This was particularly pronounced among participants with incurable cancers, as they strived to make sense of contradictions within cancer survivorship. CONCLUSION: The findings offer in-depth insights into the complexity and nuances of cancer survivorship. Such insights can contribute to facilitating successful and open-ended communication between cancer care providers, people with cancer and their families.

Losing ground, losing sleep: Local economic conditions, economic vulnerability, and sleep.

Medical research shows that healthy sleep has benefits for human wellbeing. We contribute to the emerging social-epidemiological literature on the social determinants of sleep by considering how living in an area with poor economic circumstances can result in sleep loss through financial worry, uncertainty and stress. We use multilevel regression models and nationally-representative data from the Household, Income and Labour Dynamics in Australia Survey (n = 9181) and find that individuals who live in areas with high unemployment rates or experience individual-level economic vulnerability sleep less than comparable individuals in areas with low unemployment rates, or who do not experience financial hardships. The negative association between local economic conditions and sleep duration is substantially stronger amongst economically vulnerable individuals. This highlights the importance of considering multiple levels in the analysis of health inequalities, as status and location can intersect to produce and reproduce disadvantage systems.

What prevents the intravenous to oral antibiotic switch? A qualitative study of hospital doctors' accounts of what influences their clinical practice.

OBJECTIVES: Escalating antimicrobial resistance worldwide necessitates urgent optimization of antimicrobial prescribing to preserve antibiotics for future generations. Early intravenous (iv) to oral switch campaigns are one strategy that hospital-based antimicrobial stewardship programmes can incorporate to minimize inappropriate antibiotic use. Yet, iv antibiotics continue to be offered for longer than is clinically indicated, increasing hospital length of stay, increasing costs and placing patients at risk (e.g. cannula-related infections). This study aims to identify why this inappropriate prescribing trend continues. METHODS: Twenty doctors (9 females and 11 males) working at a teaching hospital in north-east England participated in semi-structured interviews about their experiences of antibiotic use. NVivo10 software was used to conduct a thematic content analysis of the full interview transcripts driven by the framework approach. Results are reported according to COREQ guidelines. RESULTS: Decisions around the choice of iv over oral antibiotics were influenced by three key issues: (i) consumerism, i.e. participants were concerned about the risk of litigation or complaints if patient expectations were not met; (ii) hierarchy of the medical team structure limited opportunities for de-escalation of antibiotics; and (iii) iv antibiotics were perceived as more potent and having significant mythical qualities, which participants acknowledged were not necessarily evidence based. CONCLUSIONS: The iv to oral switch interventions should tailor strategies to demystify iv versus oral antibiotic efficacy, engage consumers around the negative effects of iv antibiotic overuse and examine strategies to streamline team decision-making. Addressing these issues has the potential to reduce inappropriate antibiotic use and resistance.

A qualitative study of hospital pharmacists and antibiotic governance: negotiating interprofessional responsibilities, expertise and resource constraints.

BACKGROUND: Antibiotic treatment options for common infections are diminishing due to the proliferation of antimicrobial resistance (AMR). The impact of Antimicrobial Stewardship (AMS) programs seeking to preserve viable antibiotic drugs by governing their use in hospitals has hitherto been limited. Pharmacists have been delegated a critical role in antibiotic governance in AMS teams within hospitals but the experience of pharmacists in influencing antibiotic use has received limited attention. In this study we explore the experiences of pharmacists in antibiotic decision-making in two Australian hospitals. METHODS: We conducted 19 semi-structured interviews to explore hospital-based pharmacists' perceptions and experiences of antibiotic use and governance. The analysis was conducted with NVivo10 software, utilising the framework approach. RESULTS: Three major themes emerged in the pharmacist interviews including (1) the responsibilities of pharmacy in optimising antibiotic use and the interprofessional challenges therein; (2) the importance of antibiotic streamlining and the constraints placed on pharmacists in achieving this; and (3) the potential, but often under-utilised expertise, pharmacists bring to antibiotic optimisation. CONCLUSIONS: Pharmacists have a critical role in AMS teams but their capacity to enact change is limited by entrenched interprofessional dynamics. Identifying how hospital pharmacy's antibiotic gatekeeping is embedded in the interprofessional nature of clinical decision-making and limited by organisational environment has important implications for the implementation of hospital policies seeking to streamline antibiotic use. Resource constraints (i.e. time limitation and task prioritisation) in particular limit the capacity of pharmacists to overcome the interprofessional barriers through development of stronger collaborative relationships. The results of this study suggest that to enact change in antibiotic use in hospitals, pharmacists must be supported in their negotiations with doctors, have increased presence on hospital wards, and must be given opportunities to pass on specialist knowledge within multidisciplinary clinical teams.

What role do pharmacists play in mediating antibiotic use in hospitals? A qualitative study.

OBJECTIVE: To understand Australian hospital pharmacists' accounts of antibiotic use, and the potential role of pharmacy in antibiotic optimisation within a tertiary hospital setting. DESIGN, SETTING AND PARTICIPANTS: Qualitative study, utilising semistructured interviews with 19 pharmacists in two hospitals in Queensland, Australia in 2014. Data was analysed using the framework approach and supported by NVivo10 qualitative data analysis software. RESULTS: The results demonstrate that (1) pharmacists' attitudes are ambivalent towards the significance of antibiotic resistance with optimising antibiotic use perceived as low priority; (2) pharmacists' current capacity to influence antibiotic decision-making is limited by the prescribing power of doctors and the perception of antibiotic use as a medical responsibility; and, (3) interprofessional and organisational barriers exist that prevent change in the hospital setting including medical hierarchies, limited contact with senior doctors and resource constraints resulting in insufficient pharmacy staffing to foster collaborative relationships and facilitate the uptake of their advice. DISCUSSION: While pharmacy is playing an increasingly important role in enhanced antibiotic governance and is a vital component of antimicrobial stewardship in Australia, role-based limitations, interprofessional dynamics and organisational/resource constraints in hospitals, if not urgently addressed, will continue to significantly limit the ability of pharmacy to influence antibiotic prescribing.