In the Journals

In the Journals, September 2019

Below you may find this month’s “In the Journals” updates.

American Anthropologist

Toward an Integrated Anthropology of Infant Sleep
Helen L. Bell, Cecilia Tomori & James J. McKenna

This article provides a novel synthesis of anthropological research on infant sleep, focusing on work in biological and sociocultural anthropology in the past decade. First, we briefly review early biological anthropological research into infant sleep from 1987 to 2007, which provided the evidence base for the argument that proximate parent–infant sleep combined with lactation represents a complex set of adaptations that constitute the human evolutionary norm. This work challenged the Western pediatric infant sleep research paradigm, which positioned formula‐ or bottle‐fed solitary sleeping infants as the basis for research and universal models about human infant sleep. Next, we address how recent research has built on these foundations and extended anthropological insights into new aspects of infant sleep. Biological anthropologists, who continue to lead this research, have advanced into the hormonal and behavioral ecology of parent–infant sleep and trade‐offs in nighttime care and parent–infant conflict. Moreover, they have made significant progress in translating anthropological research into policy and practice in clinical and health delivery settings. Until recently, sociocultural anthropology has primarily addressed infant sleep as part of broader endeavors, without an explicit focus on infant sleep. We highlight key ethnographic works that shed light on the cultural normalcy and interembodied experience of shared maternal–infant sleep with breastfeeding that help de‐center Western discourses of infant sleep. We conclude by discussing future research agendas to forward an integrated anthropology of human infant sleep that considers its full biological and sociocultural context. Integrated anthropological approaches to infant sleep not only present a path forward for novel cross‐subfield anthropological research but could help guide more effective and equitable approaches to maternal‐infant health.

Anthropology & Medicine

Monitoring the body: grandmothers’ ability to provide ‘expert’ care for grandchildren living with HIV in northwest Tanzania (open access)
Josein de Klerk

Drawing on long-term ethnographic fieldwork on older caregivers and their shifting roles since the introduction of antiretroviral therapy in northwest Tanzania, this article explores grandmothers’ roles in caring for grandchildren who are HIV positive and on treatment. While AIDS treatment programmes usually focus on cultivating expert patients who can perform self-care, this study focuses on older caregivers and how they become experts in caring for their grandchildren living with HIV. How is expert care enacted and what supports or limits its quality? Based on observations and in-depth interviews, this article argues that grandmothers become ‘expert caregivers’ by merging knowledge acquired in the clinic and support groups with intimate practices of grandparental care. However, the grandmother’s gendered and generational position within kin networks affects her ability to provide expert care. The findings indicate that in analysing treatment outcomes among adolescents, it is important to understand the broader family dynamic that influences the actual possibility of expert caregivers to support children living with HIV.

Facets of clinical stigma after attempted suicide in Mumbai, India
Mitchell G. Weiss & Shubhangi R. Parkar

Community stigma studies may neglect clinically relevant experience and views of stigma that are important features of mental health problems. After attempting suicide, patients in a hospital emergency ward in Mumbai, India, were assessed for stigma referring to underlying prior problems motivating their deliberate self-harm (DSH) event, the DSH event itself and serious mental illness generally based on both anticipated community views and distinctive personal views. In this cultural epidemiological study of 196 patients, assessment items and four corresponding indexes were analysed and compared on a four-point scale, 0 to 3, for prominence of indicated stigma. Narratives from patients with high, low and discordant levels of stigma for prior problems and DSH events were analysed and compared. Disclosure, critical opinions of others and problems to marry were greater concerns for DSH events than prior problems. Problem drinking, unemployment, and sexual or financial victimization were common features of prior problems. Impulsivity of the DSH event and externalizing blame were features of lower levels of stigma. Ideas about most people’s views of serious mental illness were regarded as more stigmatizing than patients’ prior problems and DSH event; patients’ personal views of serious mental illness were least stigmatizing. Findings suggest linking suicidality and stigmatized mental illness may discourage help seeking. Suicide prevention strategies should therefore emphasize available help needed for severe stress instead of equating suicidality and mental illness. Findings also indicate the relevance of assessing clinical stigma in a cultural formulation and the value of integrated qualitative and quantitative stigma research methods.

‘They’ll inject you and you’ll die’: from medication non-compliance to acceptance in Guinea’s Ebola treatment units
Kelley Sams, Alice Desclaux, & Souleymane Sow

During the 2013–2016 West African Ebola epidemic, medical emergency response teams negotiated a context marked by public hysteria and fear to prevent the spread of the virus and treat those already infected. However, the presence and work of Ebola response teams added to suspicions provoked by the rapid increase in numbers of dead and dying and by locally unintelligible emergency measures. Based on data collected from 40 young adult ‘survivors’ between 16 and 29 years of age who were hospitalized for Ebola during the epidemic, this article examines how pharmaceutical treatments were accepted (or not) by patients in ebola treatment units (ETU). Three key questions guide this analysis: (1) Did hospitalized individuals adhere with or refuse treatments offered at ETUs? (2) Did their attitudes change over the course of their hospitalization? (3) Which factors influenced refusal of treatment or compliance? To the authors’ knowledge, no previous studies have explored the resistance of hospitalized patients to treatment in Ebola centers. This article, in addition to exploring patients’ practices and related perceptions of treatment with evolving meanings in this outbreak crisis situation, also presents practical recommendations for future Ebola interventions as well as theoretical knowledge about the circulation and transformation of socially constructed representations of medications.

Not-knowing and the proliferation of assumptions: local explanations of cutaneous leishmaniasis in Suriname (open access)
Sahienshadebie Ramdas & Sjaak van der Geest

Why do patients and others confronted with cutaneous leishmaniasis (CL) – a parasitic skin disease – in the hinterland of Suriname, South America, provide a dazzling variety of aetiological explanations for one single illness? And how do these explanations reflect local knowledge of and interest in the origin of illness? In this article, we explore these questions using the concept of ‘not-knowing’, as introduced by Murray Last in 1981. One of Last’s conclusions is that ‘don’t knows’ or ‘don’t cares’ reflect people’s disinterest in medicine. The aim of this article, however, is to draw attention to another aspect of not-knowing: it may lead to a proliferation of explanatory assumptions, unhindered by precise knowledge. In other words, multiple explanations mask not-knowing, which is from a methodological point of view a rarely observed element in social science research and constitutes an important addition to Murray Last’s well known argument. The paper describes findings based on anthropological fieldwork carried out between September 2009 and December 2010 at the Dermatology Service in Suriname’s capital Paramaribo and among 205 CL patients and 321 inhabitants in various communities in the hinterland. As this article shows, both knowing and not-knowing are rooted in the various contexts of people’s daily lives and reflect their historical, socio-cultural, occupational, educational, biological, environmental, and public health-related conditions. Public health authorities should explore not-knowing more seriously in their efforts to prevent illness, since knowing about not-knowing is valuable in the design of health education and prevention programmes.

Situating biologies of traditional Chinese medicine in Central Europe
Tereza Stöckelová & Susanna Trnka

Since the concept of ‘local biologies’ was proposed in the 1990s, it has been used to examine biosocial processes that transform human bodies in similar and different ways around the globe. This paper explores understandings of biosocial differentiation and convergence in the case of Traditional Chinese Medicine (TCM) in the Czech Republic. Specifically, it examines how Czech TCM practitioners view TCM as universally applicable while fine-tuning it to situated biosocial conditions, experimenting with the compatibilities of various human and plant bodies as part of their generalised, clinical practice. Drawing upon ethnographic research among TCM practitioners in the Czech Republic, it suggests that in addition to the individualization of TCM therapeutics to suit particular patients, Czech TCM is characterised by collective particularization, shaped by local concerns over ethnic, environmental and cultural differences. By looking critically at TCM practitioners’ sensitivities to localised biological similarities and differences it aims to contribute to understandings of the expansion of TCM in Central Europe, as well as more broadly to current social science debates over the risks and opportunities inherent in abandoning the assumption of a universal human body and biology.

The Embodiment of a floating signifier
Roland Littlewood & Ellie Reynolds

As described in ethnographies, the ‘floating signifiers’ of social anthropology appear akin to similar categories in contemporary Western societies such as energy. Both may be embodied in actual experience. The practice of ritual orgasm, Pra-Na, and its relation to the group’s cosmology, are intrinsic to a religio-therapeutic community in San Francisco whose ideas derive from reified Western notions of ‘vital energy’ along with popular Chinese medicine, and in which the second author conducted fieldwork involving participant observation between 2008 and 2009. The article examines closely the formulations of ‘energy’ in the Western world, and similarities to non-Western concepts such as Melanesian mana, and asks whether the experience of ritualised orgasm by members of the group leads to their notion of cosmic energy, or whether the understanding of embodied energy is purely arbitrary from a somatic perspective. With reference to Durkheim’s ([1912]1976. The Elementary Forms of the Religious Life. London: Allen & Unwin) ­effervescence, we suggest the former is most likely.

BioSocieties

Moral hierarchies within autism parenting: Making parent-therapists and perpetuating disparities within contemporary China
Emily Xi Lin

Drawing upon 18 months of ethnographic fieldwork in China from 2013 to 2014, this article argues that moral hierarchies within autism parenting in fact reproduce local socioeconomic inequalities. In China, medical specialists, special education teachers and prominent parent advocates attempt to manage autism in a context of scarce resources by teaching parents how to serve as their children’s lifelong therapists. Yet, by focusing primarily on parents’ love for their children, while neglecting pragmatic issues related to social–economic disparities, autism advocates fail to understand the difficulties of parents with few socioeconomic resources. I illustrate my arguments by delving deeply into two case studies which illustrate both extremes of the moral hierarchy in autism parenting within China. In ethnographically attending to how parents are made into behavioral therapists and the moral hierarchies within autism parenting in China, this paper describes a culturally specific adoption of ABA. This article argues that scholars and local disability advocates need to pay closer attention to local particularities, including cultural histories of parenting, as well as the complex interactions between disability and social and economic inequalities, so as to better comprehend and address the immediate, existential, and long-range challenges which parents with little social capital face in managing autism.

Performativity and a microbe: Exploring Mycobacterium bovis and the political ecologies of bovine tuberculosis
Philip A. Robinson

Mycobacterium bovis, the bacterium responsible for causing bovine tuberculosis (bTB) in cattle, displays what I call ‘microbial performativity’. Like many other lively disease-causing microorganisms, it has an agency which is difficult to contain, and there is a need for fresh thinking on the challenges of dealing with this slippery and indeterminate microbe. As a practising veterinary scientist who side-stepped mid-career into a parallel training in the social sciences to view bTB from an alternative perspective, I create an interdisciplinary coming-together where veterinary science converges with a political ecology of (animal) health influenced by science and technology studies (STS) and social science and humanities scholarship on performativity. This suitably hybridized nexus creates a place to consider the ecologies of a pathogen which could be considered as life out of control. I consider what this means for efforts to eradicate this disease through combining understandings from the published scientific literature with qualitative interview-based fieldwork with farmers, veterinarians and others involved in the statutory bTB eradication programme in a high incidence region of the UK. This study demonstrates the value of life scientists turning to the social sciences to re-view their familiar professional habitus—challenging assumptions, and offering alternative perspectives on complex problems.

Digital orphans: Data closure and openness in patient-powered networks
Niccolò Tempini & Lorenzo Del Savio

In this paper, we discuss an issue linked to data-sharing regimes in patient-powered, social-media-based networks, namely that most of the data that patient users share are not used to research scientific issues or the patient voice. This is not a trivial issue, as participation in these networks is linked to openness in data sharing, which would benefit fellow patients and contributes to the public good more generally. Patient-powered research networks are often framed as disrupting research agendas and the industry. However, when data that patients share are not accessible for research, their epistemic potential is denied. The problem is linked to the business models of the organisations managing these networks: models centred on controlling patient data tend to close networks with regard to data use. The constraint on research is at odds with the ideals of a sharing, open and supportive epistemic community that networks’ own narratives evoke. This kind of failure can create peculiar scenarios, such as the emergence of the ‘digital orphans’ of Internet research. By pointing out the issue of data use, this paper informs the discussion about the capacity of patient-powered networks to support research participation and the patient voice.

The rise of statins in Denmark: Making the case for a localized approach to the routinization of pharmaceutical prevention of cardiovascular disease
Sofie Rosenlund Lau, John Sahl Anderson, Flemming Dela, Bjarke Oxlund

This article provides a socio-historical account of the rise of preventive medicine in Denmark by exploring details of how pharmaceutical cholesterol-reduction became routinized as a standard of care. While other accounts of mass-prevention with statins primarily focus on the role of the pharmaceutical industry, we aim to show how routinization in a welfare state with free access to healthcare and where direct-to consumer advertisement is prohibited bring to the fore other actors and entities that are pivotal for the transformation of new treatment logics. Based on the close scrutiny of three decades of discussions in the Danish Weekly Medical Journal and interviews with key experts, we point to the important role of general practitioners as the main executors of preventive medicine in practice. Furthered by the introduction of new techno-scientific innovations such as guidelines and assessment tool, the routinization of statins in Denmark happened as a bottom-up process championed by a local group of therapeutic reformers who successfully manoeuvered the realms of science, politics and practice in order to transform contested global evidence into the very foundation of a new standard of care. We argue that localized processes of routinization are incredibly important for any understanding of pharmaceuticalization.

Liminality in practice: A case study in life sciences research (open access)
Megan Clinch, Sara Shaw, Richard Ashcroft, Deborah Swinglehurst

Contemporary health challenges (e.g., diabetes, climate change, antimicrobial resistance) are underpinned by complex interrelationships between behavioural, cultural, social, environmental and biological processes. Current experimental systems are only partially relevant to the problems they investigate, but aspirations to embed interdisciplinary working and community engagement into life scientists’ work in response to this partiality have proven difficult in practice. This paper explores one UK university-based life sciences research initiative as it seeks to develop modes of working which respond to this complexity. Drawing on ‘liminal hotspots’ as a sensitising concept, we explore how participating academics articulate complex problems, knowledge-making, interdisciplinary working and community engagement. Our analysis shows they become recurrently ‘trapped’ (institutionally and epistemologically) between fixed/universalised cosmologies of biology/disease, and more contemporary cosmologies in which biology and disease are conceptualised as situated and evolving. Adopting approaches to community organising based on ‘process pragmatism’, we propose ways in which life scientists might radically reorganise their practice and move beyond current limiting enactments of interdisciplinary and community engaged working. In doing so, we claim that the relevance and ‘humanness’ of life science research will be increased.

How to feel about war: On soldier psyches, military biopolitics, and American empire
Kenneth MacLeish

The basic structure of contemporary military biopolitics, in which military bodies and minds are kept alive and allowed to die, entails both an institutional problem of how to shore up life that is exposed to harm and a cultural problem of how to reckon with a routinized trade in life and death that happens not incidentally, but on purpose. Amidst this tension, the military psyche becomes both an inhabited, embodied site and an imaginative point of reference for the question of how to feel about war. This article takes stock of the contemporary landscape of war-related mental affliction via three relatively novel interventions: military suicide prevention, the framing post-traumatic stress as “moral injury,” and resiliency training meant to inoculate soldiers against the stress of the battlefield. Drawing on a range of clinical and media sources and ethnographic research with post-9/11 military personnel, I show how each of these efforts constructs specific forms of war-related psychic destruction as objects of public and institutional concern, normalizes the institutional arrangements that produce it, and informs public perceptions of what war is by constructing figures of what it does to those who fight it.

Cambridge Encyclopedia of Anthropology (open access)

Autism
Ben Belek

The concept of autism is historically contingent. It did not exist, in any proper sense, before it was invoked by medical and mental health professionals in the twentieth century. This entry aims to shed light on this relatively recent concept. First, it contextualises autism within the broader social, epistemological, and political circumstances of its emergence and ongoing negotiation, showing autism to be a dynamic concept, whose meaning is constantly in flux. Second, it revisits some of the more insightful or influential analyses that autism has received over the years in anthropology and adjacent disciplines. And third, it illustrates that anthropologists have been particularly attuned to everyday experiences of autism, comparing it to other forms of human difference while occupying an ambivalent stance towards biomedical approaches to it. A discussion on how autism might matter for the discipline of anthropology features very briefly in the conclusion.

Culture, Medicine, and Psychiatry

Overlaps and Disjunctures: A Cultural Case Study of a British Indian Young Woman’s Experiences of Bulimia Nervosa (open access)
Sunita Channa, Anna Lavis, Charlotte Connor, Newman Leung, Max Birchwood

Eating disorder diagnoses are characterised by a pattern of disordered eating behaviour alongside symptoms such as body dissatisfaction and preoccupation with food, weight or shape (APA in Diagnostic and statistical manual of mental disorders, DSM-5, APA, Washington, DC, 2013). Incidence rates for eating disorders have increased during the last 50 years. However, epidemiological studies have suggested that such trends may not be a true representation of the occurrence of these illnesses in the general population, with figures underestimated due to reduced help seeking and poor access to care, particularly amongst ethnic minorities. This case study explores the experiences of a young British Indian woman with bulimia nervosa. Arising from an in-depth semi-structured interview, analysed with interpretative phenomenological analysis, her narrative offers a critical lens onto how diverse fragments of cultural practices and meanings come together to produce the clinical category of ‘bulimia.’ It thereby offers an alternative portrait of relationships between eating disorders and ‘culture,’ one that goes beyond a framing of these illnesses as culture inscribed on the body. Interrogating relationships between culture and the development, expression and maintenance of bulimia is suggested to be key to forging culturally-sensitive understandings of this illness; this paper begins to provide the evidence base for the design and development of appropriate support services, thereby aiming to contribute to a reduction in health inequalities and barriers to treatment.

Traditional Chinese Medicine Explanatory Models of Depressive Disorders: A Qualitative Study (open access)
Wan Kam, Zhang-Jin Zhang, Sofie Bäärnhielm

Traditional Chinese medicine (TCM) is an alternative medical system utilised by many Chinese. However, the knowledge of TCM concepts of depression is limited amongst clinicians with training in Western biomedicine. The purpose of this study was to obtain a better understanding of the conceptualisation of depression from a group of TCM practitioners. Semi-structured interviews in Chinese were carried out with 10 TCM practitioners in Hong Kong. A case description of major depression disorder (MDD) was used as a basis. Interview texts were transcribed, translated and analysed using qualitative content analysis. Most informants identified the case as a depression pattern, a term that lacked clear definition and standardised criteria. The mechanism of disease for MDD symptoms were regarded to be liver-qi dysregulation and an imbalance of yin and yang. The TCM practitioners implemented individualised diagnosis, treatment, and a holistic concept without clear distinction between the mind and the body. This contrasted with the biomedical tradition of separating psychologisation and somatisation. The meanings given to the concept of depression did not correspond with current DSM or ICD definitions, and the TCM normativity can result in variations in explanatory models.

Keeping Our Mouths Shut: The Fear and Racialized Self-Censorship of British Healthcare Professionals in PREVENT Training (open access)
Tarek Younis & Sushrut Jadhav

The PREVENT policy introduced a duty for British health professionals to identify and report patients they suspect may be vulnerable towards radicalisation. Research on PREVENT’s impact in healthcare is scant, especially on the lived experiences of staff. This study examined individual interviews with 16 critical National Health Service (NHS) professionals who participated in mandatory PREVENT counter-radicalisation training, half of whom are Muslims. Results reveal two themes underlying the self-censorship healthcare staff. The first theme is fear, which critical NHS staff experienced as a result of the political and moral subscript underlying PREVENT training: the ‘good’ position is to accept the PREVENT duty, and the ‘bad’ position is to reject it. This fear is experienced more acutely by British Muslim healthcare staff. The second theme relates to the structures which extend beyond PREVENT but nonetheless contribute to self-censorship: distrustful settings in which the gaze of unknown colleagues stifles personal expression; reluctant trainers who admit PREVENT may be unethical but nonetheless relinquish responsibility from the act of training; and socio-political conditions affecting the NHS which overwhelm staff with other concerns. This paper argues that counter-terrorism within healthcare settings may reveal racist structures which disproportionality impact British Muslims, and raises questions regarding freedom of conscience.

Initiating Change: Negotiations of Subjectivity in a Danish Activation Programme for Young Adults with Psychosocial Problems and Common Mental Disorders
Julie Høgsgaard Andersen, Tine Tjørnhøj-Thomsen, Susanne Reventlow, & Annette Sofie Davidsen

An increasing number of young adults in Denmark experience difficulties in completing their education and holding down a job. Many of these young adults have psychosocial problems and common mental disorders. To retain public income support they must attend education and work-directed activities, known as ‘activation programmes’. Based on ethnographic fieldwork, this study presents an analysis of how one such programme unfolds in practice and how the participants engaged with the activities and negotiated the underlying rationales. We argue that the activities involved in the programme constitute ‘biographical techniques’ that entail a configuration of the participants as being responsible for their own biographies and having the capability to solve their problems themselves. The participants challenged this configuration of subjectivity by recounting complex or immediate problems that could not be solved through biographical techniques and by refusing to deal with their life stories as a way of configuring their futures. Biographical techniques limited the possibilities for grappling with the complexity of the participants’ problems. We conclude that the participants are therefore subjected to biographical coercion because forms of subjectivity other than biographical subjectivity are disregarded.

Identity, Subjectivity, and Disorders of Self in Psychosis
Suze G. Berkout, Juveria Zaheer, & Gary Remington

Alterations in self-experience are increasingly attended to as relevant and important aspects of schizophrenia, and psychosis more broadly, through a burgeoning self-disorders (SD) literature. At the same time, issues of self, subject, and subjectivity within schizophrenia-spectrum illnesses have also gained attention from researchers across the social sciences and humanities, and from ethnographic research especially. This paper examines the subjective experience of disruptions in self-identity within a cohort of first episode psychosis (FEP) service users, critically engaging with the SD literature and bringing it into conversation with social sciences and humanities scholarship on self and schizophrenia. Drawing findings from an ongoing ethnographic study of young peoples’ experiences with psychosis, we explore meanings of mental distress relating to psychotic episodes and attend to issues of self, identity, and subjectivity. We critique the division between “normal” and “pathological” self-experience that is endorsed within the SD literature, arguing against the notion that fragmentation of self-experience in schizophrenia-spectrum illnesses is indicative of psychopathology. We highlight how experiences categorized as psychosis are also important and complete aspects of one’s social world and inner life and explore the ways in which at least some aspects of disruptions of self-identity stem from clinical situations themselves—in particular, from asymmetries of power within the mental health system. Relating our findings to feminist, postcolonial, and disability studies’ approaches to the “self,” we emphasize the complex interplay between interpersonal, cultural, and structural aspects of self-experience within FEP.

Technologies of the Social: Family Constellation Therapy and the Remodeling of Relational Selfhood in China and Mexico
Sonya E. Pritzker, Whitney L. Duncan

In this article, we investigate how an increasingly popular therapeutic modality, family constellation therapy (FCT), functions simultaneously as a technology of the self (Foucault, Technologies of the self: a seminar with Michel Foucault, University of Massachusetts Press, Amherst, 1988) as well as what we here call a “technology of the social.” In FCT, the self is understood as an assemblage of ancestral relationships that often creates problems in the present day. Healing this multi-generational self involves identifying and correcting hidden family dynamics in high-intensity group sessions where other participants represent the focus client and his/her family members, both alive and deceased. Drawing on ethnographic data collected in multiple FCT workshops in Beijing, China and Oaxaca City, Mexico, we show how FCT ritually reorganizes boundaries between self and other in novel ways, creating a collective space for shared moral reflection on troubling social, historical, and cultural patterns. By demonstrating the ways in which FCT unfolds as both a personal and social technology, this article contributes to ongoing conversations about how to effectively theorize sociality in therapeutic practice, and problematizes critical approaches emphasizing governmentality and commensuration.

“How Can We Help You”: Mental Health Practitioners’ Experiences of Service Provision in Northern Namibia
Theodore T. Bartholomew & Shelene G. Gentz

Although 12–13% of Namibians are reported to struggle with psychological distress, very few practitioners are available to provide mental health services in Namibia. Those practitioners who are available are often trained from Western counseling and psychiatric perspectives that may not readily align to beliefs about illness held constructed in Namibian cultures. Institutional effort is invested in the education and use of mental health practitioners, including counselors, social workers, nurses, psychologists, and psychiatrists. However, little is known about the experiences of these providers. Therefore, this study, a grounded theory ethnography, was undertaken as part of broader ethnographic work to understand how mental health practitioners (N = 7) in Northern Namibia view their work with Aawambo Namibians given that Namibian mental health practitioners are few but embedded in the country’s health care system. Four categories were identified in analyses: Provision of Mental Health Services in the North, Practitioners’ Conceptualizations of Psychological Distress: Western and Aawambo Influences, Beliefs about Mental Health Services in the North, and Integration of Traditional Treatment and Counseling. Results are discussed with respect to cultural competence in Namibian mental health practice and potential for integrating traditional practices and mental health services.

Contemporary Drug Problems

Progress at the State Level Versus Recent Regress at the Federal Level: Changes in the Social Consequences of the U.S. War on Drugs
Eric L. Jensen, Clayton Mosher, Jurg Gerber & Kate Angulski

Fifteen years ago, Jensen, Gerber, and Mosher drew attention to the societal costs of the U.S. war on drugs. They argued that while criminologists had focused on the impact of this war on the U.S. criminal justice system, other impacts had been under-researched. Whereas some research along these lines has been done that we review here briefly, some of the “objective” conditions of the war on drugs have changed in the intervening years. The primary aim of the current article is to update these conditions. In brief, we have witnessed progress at the U.S. state level in terms of adverse social consequences of the war on drugs, but a significant recent regress at the federal level. Among others, there are significant new restrictions to various federal programs, often disproportionately so for members of racial minorities.

Social and Political Factors Associated With State-Level Legalization of Cannabis in the United States
Joanne Spetz, Susan A Chapman, Timothy Bates, Matthew Jura, Laura A. Schmidt

Thirty-three U.S. states and the District of Columbia (DC) have legalized the use of marijuana for medicinal purposes and 10 states and DC have legalized marijuana for adult recreational use. This mirrors an international trend toward relaxing restrictions on marijuana. This article analyzes patterns in marijuana laws across U.S. states to shed light on the social and political forces behind the liberalization of marijuana policy following a long era of conservatism. Data on U.S. state-level demographics, economic conditions, and cultural and political characteristics are analyzed, as well as establishment of and levels of support for other drug and social policies, to determine whether there are patterns between states that have liberalized marijuana policy versus those that have not. Laws decriminalizing marijuana possession, as well as those authorizing its sale for medical and recreational use, follow the same pattern of diffusion. The analysis points to underlying patterns of demographic, cultural, economic, and political variation linked to marijuana policy liberalization in the U.S. context, which deserve further examination internationally.

“I Want to See Those Memories”: Social Affordances of Mobile Phone Cameras and Social Network Sites in Collegiate Drinking
Gilbert Quintero, Henry Bundy, Michelle Grocke

Alcohol use remains a prominent feature of American collegiate social life. Emerging technological developments, particularly the proliferation of mobile phone cameras and the easy sharing of digital images on social network sites (SNS), are now widely integrated into these drinking practices. This article presents an exploratory study examining how 40 students on a midsized college campus in the interior Pacific Northwest incorporate these technologies into their drinking activities. Data from semistructured interviews are considered within the theoretical framework of “affordances,” which classifies material technologies (camera phones, SNS) as simultaneously inhabiting the role of artifact shaped by human action and of object that influences human conduct. Our data suggest that although contemporary college drinking reflects long-standing practices, cameras, digital images, and social media introduce new dimensions to college alcohol consumption and memory-making processes. These technologies are used to chronicle and archive the festive, social aspects of drinking; commemorate the good times that make up the college experience; and capture proud or incautious displays of excessive drinking. Our examination of emergent college drinking practices seeks to extend understandings of contemporary trends in collegiate alcohol use beyond the discourse of risk and indiscretion to include other important social and cultural dimensions of these phenomena, including pro-social aspects of these practices and the social affordances provided by digital image sharing and reminiscing.

Stop Smoking the Easyway: Addiction, Self-Help, and Tobacco Cessation
Donncha Marron

This article examines Easyway, a popular clinical and self-help method for the treatment of smoking addiction established by the late Allen Carr in 1984. It begins by addressing how smoking has come to be constituted as a neuropharmacological addiction and some of the issues and concerns raised against this in the social sciences. After situating its theoretical and empirical focus, the article then proceeds with an interpretative thematic analysis of a selection of Easyway self-help texts. The aims here are as follows: firstly, to show how Easyway, as a discourse, constitutes the problem of nicotine addiction in novel and distinctive ways; secondly, to elaborate how the Easyway texts seek to govern readers—paradoxically, through their free capacity for reflection, introspection, and action—to overcome their situated addiction to smoking; and thirdly, to identify and locate the significance of the author’s implicit claims to charisma in underpinning his authority to know and treat nicotine addiction.

East Asian Science, Technology and Society

Less Reproduction, More Production: Birth Control in the Early People’s Republic of China, 1949–1958 (open access)
Sarah Mellors

In the early People’s Republic of China (PRC), Communist officials initially placed strict constraints on birth control use, encouraging high fertility rates. However, in an effort to enhance agricultural and industrial productivity, such restrictions were gradually repealed and by the 1970s, aggressive promotion of family planning had become the norm. Drawing on both archival and oral history, this article considers the lived experience of birth control use from the founding of the People’s Republic until 1958, a period that is often overlooked in studies of reproduction and contraception in modern China, but that had important implications for later trends. Despite claims that discussion of sexuality was suppressed in the PRC and an early ban on certain publications related to sexual hygiene, a considerable amount of literature on sex and birth control was published in major cities in the 1950s. Narratives on sex and birth control in women’s magazines and sex handbooks, however, varied widely and access to birth control and surgeries, such as abortions and sterilizations, differed dramatically according to location, class, and education level. This essay probes the circumstances under which women or couples practiced birth control while demonstrating the diversity of contraceptive discourses and practices in the early People’s Republic. Though underexplored, the early years of the PRC remain critical to histories of reproduction in China because many of the gender dynamics, socioeconomic pressures, and cultural preferences that informed contraceptive practices in the 1950s continued to do so for decades to come.

Ethos

Cultivating Affection‐Laden Hierarchy: Embodied Moral Socialization of Vòng Tay (Khoanh Tay) with Children in Southern Vietnam
Heidi Fung Mai Thị Thu

By adopting a discursive practice approach, this work examines how embodied deference rituals were practiced by Vietnamese children in the Mekong Delta region. Sixty‐two video‐recorded events of vòng tay/khoanh tay performed by 23 children (ages 1.5 to 12 years) were identified; of those, 51 events performed by 12 preschool‐aged children were most rigorous and demanding. On the occasions of greeting/departing, thanking, and apology/discipline and through various communicative channels, four‐generation caregivers played different roles to coach children in proper postural display and verbal respect with affection. Children actively participated in these recurrent family interactions and acquired the cultural meaning of affection‐laden social hierarchy at a young age. Such socialization practices ensure the stability of a hierarchical structure, strengthen the mutual bond between novices and their seniors or superiors, and lay the sociocultural foundation of politeness, filial piety, and sacrifice in the family and in society at large.

Relational Affliction: Reconceptualizing “Mass Hysteria”
Aidan Seale-Feldman

An ethnographic exploration of “mass hysteria” in Nepal reconsiders existing anthropological treatments of this form of affliction as gendered resistance. In Nepal, affected communities and girls dispute psychosocial counselors and anthropologists on conceptual grounds. These conflicts revolve around two distinct understandings of the subject of affliction. The subject of “mass hysteria” takes a liberal feminist form in which symptoms reveal resistance to power, while for the subject afflicted by ghosts and spirits, bhut‐pret laagne, symptoms reveal the intertwined relationality between bodies and the world. I argue that by shifting attention away from questions of resistance, desire, and truth of the individual, we find that the concepts of chopne and bhut‐pret laagne are concerned with the transfer, sharing, and relationality of affliction. By placing Nepali and Euro‐American conceptualizations in dialogue, haunting is approached not as idiom or metaphor but as an analytic with which to construct new conceptual frameworks.

Ambiguity as Dream Mentation: Supermasculinity and Ambivalence in American Dreams
Jeannette Mageo

Ambiguity, this paper argues, is not merely a property of dream imagery, but ignites a process that is dreaming thinking. When images are ambiguous, the mind cannot fix on a single meaning. Hence dream ambiguity catalyzes a play of possible meanings that implicitly raises questions, not only about personal memories but also about those cultural models that these memories evoke. Dream thinking, then, renders people’s ongoing subjective reactions to culture into images. Through data from a 2004 to 2009 study of Northwest American student dreams and life histories, I propose that people think within dreams by representing daily ambivalences as visual ambiguities. Excerpts from this dream study illustrate seven types of visual ambiguity in dreams. Implicit in this taxonomy is a method of cultural dream interpretation that I present through an analysis of a full dream from a young man, Clarence. Through this analysis I show how ambiguities in Clarence’s dream represent his ambivalence about an American masculinity model—one that may underlie the school shootings that are now so common in the United States.

Rethinking Depth Metaphors with a Cosmocentric Self: The “Steep” and the “Level” in Akha Emotional Practices
Deborah E. Tooker

This study critically engages two analytic constructs: western psychological individualism (with its assumed emotional interiority) and the notion of a generic sociocentric self. By looking at the emotional practices of the Akha of Northern Thailand in a nonmodern context, I aim to show the distinctiveness of a particular type of socio‐ and cosmo‐centric self, that of the “microcosmic,” “level” self, which is not a depth self. This analysis examines the semiotic ideology in which Akha emotions and self concepts are co‐constituted as part of a process of inner/outer alignment with both communal and cosmic templates that affect the flow of a life force energy. In addition, Akha social dynamics resist and deflect from the emergence of a potentially dangerous individualized depth self with emotional interiority and an inner/outer boundary, suggesting an ideological component, and, thus, the relevance of historical and political‐economic contexts in the study of emotional practices.

Sent Spirits, Meaning‐Making, and Agency in Haiti
Bonnie N. Kaiser, Joseph Reginald Fils-Aimé

In Haiti, a “sent spirit” is an experience of misfortune, such as an illness or accident, which is interpreted as intentionally sent by someone supernaturally. Sent spirits are fundamentally social narratives, reflecting links among social inequality, structural violence, and solidarity. This article focuses on the ethnographic stories of two women who experienced the death of a daughter, with one attributing the death to her own inability to care for her daughter, and the other to a sent spirit. A key question is whether these different explanations of misfortune create different possibilities for recourse to action. I explore how, in the context of gangan makout (“shaman with a sack,” free Vodou services), a sent‐spirit attribution created a means of enacting agency following misfortune. However, as contemporary Vodou institutions have shifted to a gangan ason (“shaman with a rattle/bell,” fee‐for‐service) model, sent‐spirit attributions no longer constitute a feasible avenue for enacting agency. Instead, they leave individuals facing new manifestations of structural violence in the form of marketization of rituals for healing and justice that have become out of reach for the poor. However, sent‐spirit narratives continue to perform the work of culture by displacing blame from suffering individuals.

“Soothing My Child’s Soul and My Own”: Dealing with Pregnancy Loss in Postcommunist Romania (open access)
Erica van der Sijpt

In Romania—where induced abortions were legally prohibited during communism and are now morally condemned by many—those who lose a pregnancy against their will have long been regarded with suspicion, confronted with a sense of culpability, and surrounded by silence. This ambiguity is reflected in the local terminology and the perceived etiology of loss. In this article, which is based on 15 months of fieldwork between 2012 and 2015, I illustrate the various meanings and manifestations of a silenced sense of culpability around involuntary pregnancy loss in the lives of women from Bucharest and a small town in Central Romania. I also show how many of these women attempt to break the silence around their lost fetuses and carve out a personal space of commemoration and consolation. Their informal use of forbidden religious rituals paradoxically allows them to confirm the existence of their lost little ones and to position themselves as caring, rather than culpable, mothers.

Health: An Interdisciplinary Journal for the Social Study of Health, Illness and Medicine

“I tend to forget bad things”: Immigrant and refugee young men’s narratives of distress
Carla T. Hilario, John L. Oliffe, Josephine P. Wong, Annette J. Browne, & Joy L. Johnson

Distress among young immigrant and refugee men has drawn increasing research attention in recent years. Nuanced understandings of distress are needed to inform mental health and public health programming. The purpose of this research was to examine distress from the perspectives of young immigrant and refugee men living in Greater Vancouver, British Columbia, Canada. Thirty-three young men (aged 15–22 years) from diverse immigrant and refugee backgrounds participated in interviews, which were conducted between 2014 and 2015. Data were examined using narrative analysis and theories of masculinities. Three narratives were identified—norming distress, acknowledging distress as ongoing, and situating distress. The findings reveal that the narratives offer different frames through which distress was rendered a norm, or acknowledged and situated in relation to the participants’ relationships and to masculine discourses that shaped their expressions of distress. The findings can inform initiatives aimed at providing spaces for diverse young men to acknowledge their distress and to receive support for mental health challenges.

The produsing expert consumer: Co-constructing, resisting and accepting health-related claims on social media in response to an infotainment show about food
Jana Declercq, Stéphan Tulkens, & Sarah Van Leuven

This article examines the Twitter and Facebook uptake of health messages from an infotainment TV show on food, as broadcasted on Belgium’s Dutch-language public broadcaster. The interest in and amount of health-related media coverage is rising, and this media coverage is an important source of information for laypeople, and impacts their health behaviours and therapy compliance. However, the role of the audience has also changed; consumers of media content increasingly are produsers, and, in the case of health, expert consumers. To explore how current audiences react to health claims, we have conducted a quantitative and qualitative content analysis of Twitter and Facebook reactions to an infotainment show about food and nutrition. We examine (1) to which elements in the show the audience reacts, to gain insight in the traction the nutrition-related content generates and (2) whether audience members are accepting or resisting the health information in the show. Our findings show that the information on health and production elicit the most reactions, and that health information incites a lot of refutation, low acceptance and a lot of suggestions on new information or new angles to complement the show’s information.

The daily digital practice as a form of self-care: Using photography for everyday well-being (open access)
Liz Brewster & Andrew M. Cox

Interest in the connection between involvement in digital communities and well-being has increased as these communities become more commonplace. Specific models of interaction that affect well-being have emerged; here, we examine one of those models, termed ‘digital daily practice’. Digital daily practices involve a commitment to doing one thing – exercise, photography and writing – every day and sharing it online. Participants in these practices agree that they provide an unexpected benefit of improving well-being. This article makes an in-depth examination of one digital daily practice, photo-a-day, using a practice theory framework to understand the affordances it offers for well-being. We engage with the literature on well-being and self-care, critiquing its presentation of well-being as an individual trait. We present data from an ethnographic study including interviews and observations to highlight how photo-a-day as a practice functions as self-care and how communities are formed around it. Photo-a-day is not a simple and uncomplicated practice; rather it is the complex affordances and variance within the practice that relate it to well-being. We conclude that this practice has multi-faceted benefits for improving well-being.

Incarnation and the dynamics of medical promises: DHEA as a fountain of youth hormone
Boris Hauray & Sébastien Dalgalarrondo

For more than a decade, the sociology of hope and expectations has gained growing influence in the social studies of health, medicine, and healthcare. This literature has stressed the role of representations of the future—through images, metaphors, theories, or visions—in the medical sector and analyzed the translation of these discursive contents into social practices and organizations. This article builds on these results and intends to explore a dimension that has received less attention: the incarnation of medical promises. Looking at the evolving case of a particular molecule, dehydroepiandrosterone (DHEA)—which has been promoted from the mid-1990s onwards as a “fountain of youth” pill—, we emphasize that testimonies by and portrayals of those who are undergoing a treatment with uncertain risks and benefits, and representations of their bodies in the media, can play a key role in the performativity of a medical promise. We analyze this incarnation as a specific “form of veridiction” and stress its normative dimension. This leads us to underline how evidence-based medicine and experiential knowledge—which are often analyzed as two opposite sources of information—can intricate and give rise to the same incarnation dynamics.

Risk assessment practice within primary mental health care: A logics perspective
Adam Flintoff, Ewen Speed & Susan McPherson

From the 1980s onwards, discourses of risk have continued to grow, almost in ubiquity. Ideas and practices of risk and risk aversion have extended to UK mental health care where services are expected to assess and manage risks, and high-quality clinical assessment has been revised to incorporate risk assessment. This article problematises practices of risk assessment in mental health provision, focussing on the base-rate problem. It presents an analysis of audio recordings of risk assessments completed within a primary care mental health service. The analysis is informed by a critical logics approach which, using ideas from discourse theory as well as Lacanian psychoanalysis, involves developing a set of logics to describe, analyse and explain social phenomena. We characterise the assessments as functioning according to social logics of well-oiled administration and preservation, whereby bureaucratic processes are prioritised, contingency ironed out or ignored, and a need to manage potential risks to the service are the dominant operational frames. These logics are considered in terms of their beatific and horrific fantasmatic dimensions, whereby risk assessment is enacted as infallible (beatific) until clients become threats (horrific), creating a range of potential false negatives, false positives and so forth. These processes function to obscure or background problems with risk assessment, by generating practices that favour and offer protection to assessors, at the expense of those being assessed, thus presenting a challenge to the stated aim of risk assessment practice.

Health and Place

From risky places to safe spaces: Re-assembling spaces and places in Vancouver’s Downtown Eastside
Andrew Ivsins, Vancouver Area Network of Drug Users, CeciliaBenoit, KarenKobayashi and SusanBoyd

Vancouver’s Downtown Eastside (DTES) neighbourhood is commonly associated with stigmatized and criminalized activities and attendant risks and harms. Many spaces/places in this urban neighbourhood are customarily portrayed and experienced as risky and harmful, and are implicated in experiences of structural (and physical) violence and marginalization. Drawing on 50 qualitative interviews, this paper explores how spaces/places frequently used by structurally vulnerable people who use drugs (PWUD) in the DTES that are commonly associated with risk and harm (e.g., alleyways, parks) can be re-imagined and re-constructed as enabling safety and wellbeing. Study participants recounted both negative and positive experiences with particular spaces/places, suggesting the possibility of making these locations less risky and safer. Our findings demonstrate how spaces/places used by PWUD in this particular geographical context can be understood as assemblages, a variety of human and nonhuman forces – such as material objects, actors, processes, affect, temporal elements, policies and practices – drawn together in unique ways that produce certain effects (risk/harm or safety/wellbeing). Conceptualizing these spaces/places as assemblages provides a means to better understand how experiences of harm, or conversely wellbeing, unfold, and sheds light on how risky spaces/places can be re-assembled as spaces/places that enable safety and wellbeing.

Acute exposure to violent neighborhood crime and depressive symptoms among older individuals in Colombia
Philipp Hessel, María Alejandra Martínez Botero and Jorge Cuartas

To assess the association between acute exposure to neighborhood violent crimes and depression we combined representative, individual-level and geo-coded data for individuals aged 60 years and above living in four major cities in Colombia from the 2010 Demographic and Health Survey (DHS) with objective information on the timing and location of violent crimes. Exploiting spatial and temporal variation in the occurrence of crimes we find that being acutely exposed to a violent crime is positively associated with the number of depressive symptoms.

A comparative analysis of the impacts of objective versus subjective neighborhood environment on physical, mental, and social health
Lin Zhang, Suhong Zhou, Mei-Po Kwan

Research on the relationship between neighborhood context and health outcome has attracted notable attention. However, few studies examine and compare the associations between the objective and subjective neighborhood environment and different dimensions of health. To this end, high-resolution remote sensing images and points-of-interest (POIs) data collected in Guangzhou, China, are used together with questionnaire survey data to measure the objective and subjective characteristics of the neighborhood environment. The sample includes 1029 adults selected from 34 communities in Guangzhou, China. Hierarchical linear modeling is then employed to analyze the associations between the objective and subjective neighborhood environment and three dimensions of health (physical health, mental health, and social health), as well as compare the relative strengths of and moderating mechanisms between these associations. The results indicate that significant variations in health outcomes are observed among neighborhoods, which can be explained by both personal attributes and the neighborhood environment. Although objective and subjective measures of the neighborhood environment are both linked to the three dimensions of health, physical health and social health are influenced more by objective measures, while mental health is affected more by subjective measures. Further, subjective measures have positive moderating effects on the relationship between objective measures and mental health but do not have significant moderating effects on the relationships between objective measures and physical and social health.

Local Landscapes of Breastfeeding: A comparison of breastfeeding amongst mothers in low- and high-income neighborhoods in Bristol, UK
Josie Isherwood, Kate Boyer, and Sally Dowling

This paper compares experiences of breastfeeding outside the home for women living in low-income and high-income neighborhoods of the same city. Our findings are based on an analysis of 22 interviews with breastfeeding mothers (11 in each of two study areas) undertaken in Bristol, UK in 2017. We extend existing scholarship by showing how experiences of breastfeeding vary not only at the regional level but between local areas of the same city, and outline how our findings can inform policy. We advance literature on maternal bodies by exploring how local “landscapes” of breastfeeding emerge as mothers encounter and negotiate different socio-material landscapes and locally-differentiated norms about “appropriate” maternal embodiment. We argue that these variegated interactions can lead to different orientations to space and forms of spatial practice on the part of breastfeeding mothers, as well as different kinds of maternal identities.

Associations of neighbourhood sociodemographic characteristics with depressive and anxiety symptoms in older age: Results from a 5-wave study over 15 years
I. Motoc, E.J. Timmermans, D. Deeg, B.W.J.H. Penninx and M. Huisman

We examined the long-term association between objective neighbourhood sociodemographic characteristics (index of socioeconomic position (SEP), average income, percent low-income earners, average house price, percent immigrants and urban density) with depressive and anxiety symptoms, covering five 3-year waves of the Longitudinal Aging Study Amsterdam (n = 3,772). Multi-level regression models assessed each neighbourhood-level characteristic separately, adjusting for individual-level covariates. A higher percentage of immigrants and higher urban density, but not other neighbourhood characteristics, were significantly associated with depressive and anxiety symptoms over time in models adjusted for individual SEP. Results of time interaction models indicated that the associations were stable over the 15-year period.

Using street view data and machine learning to assess how perception of neighborhood safety influences urban residents’ mental health
Ruoyu Wang, Yuan Yuan, Ye Liu, Jinbao Zhang, Penghua Liu, Yi Lu, Yao Yao

Previous studies have shown that perceptions of neighborhood safety are associated with various mental health outcomes. However, scant attention has been paid to the mediating pathways by which perception of neighborhood safety affects mental health. In addition, most previous studies have evaluated perception of neighborhood safety with questionnaires or field audits, both of which are labor-intensive and time-consuming. This study is the first attempt to measure perception of neighborhood safety using street view data and a machine learning approach. Four potential mediating pathways linking perception of neighborhood safety to mental health were explored for 1029 participants from 35 neighborhoods of Guangzhou, China. The results of multilevel regression models confirm that perception of neighborhood safety is positively associated with mental health. More importantly, physical activity, social cohesion, stress and life satisfaction mediate this relationship. The results of a moderation analysis suggest that the beneficial effects of physical activity and social cohesion on mental health are strengthened by a perception of neighborhood safety. Our findings suggest the need to increase residents’ perception of neighborhood safety to maintain mental health in urban areas of China.

Estimating ecological social capital using multi-level regression with post-stratification: A spatial analysis of psychiatric admission rates in wales
Christopher W. N. Saville

Although ecological cognitive social capital is an important predictor of mental health, measurement remains crude. Multi-level regression with post-stratification (MRP) is a technique for computing small area estimates of survey responses, used in political science but hitherto not for estimating ecological protective factors in epidemiology. National Survey for Wales 2016-17 data (N = 10,486) were used to produce MRP estimates of belonging and generalised trust for 410 middle super output areas covering Wales. These estimates were used to predict psychiatric admission rates in 2017 (N = 9978 cases). Low belonging and trust are ecological risk factors for psychiatric admissions, with a 29% (25–33%) and 25% (22–29%) increase in admissions per standard deviation decrease respectively. Equivalent results for using standard simple aggregation of survey data by area suggest 8% (4–12%) and 10% (6–14%) increases in risk per standard deviation. MRP has potential for studying ecological risk factors based on self-report measures, with greater predictive validity for incidence of psychiatric admissions than current methods.

Recession, local employment trends and change in self-reported health of individuals: A longitudinal study in England and Wales during the ‘great recession’
Sarah Curtis, Paul Norman, Richard Cookson, Mark Cherrie & Jamie Pearce

This paper contributes to a growing international literature on the
relationships between economic recession and health outcomes, which
has become particularly pertinent during the recent ‘great recession’,
affecting many countries around the world in the period since 2008.
The study is situated within the interdisciplinary field of research
concerned with the wider determinants of health, and relates to an
expanding series of publications in health geography (e.g., reviewed by
Pearce, 2018; Pearce et al., 2018) concerned with the significance of
changing environments over the lifecourse of places and how these relate
to variability in health among individual residents. We report here on
an analysis that combines information from two datasets produced by
the United Kingdom Office of National Statistics: data for Local Authorities (Local Government units in Britain), on trends over time in
economic conditions; and data from the Longitudinal Study (LS) for
England and Wales (source ONS LS), providing information on individual’s health and other personal characteristics for two time points,
before and after the onset of recession. We present results from analyses
of data on very large samples of individuals, drawn from the LS, which
are derived from the population census and followed up over time at
each decennial census. As discussed below, evidence from this kind of
approach has been identified in reviews of research in the field as relatively unusual and necessary in order to understand the relationships
involved and identify the populations most at risk of deteriorating
health during recession. Our conclusions consider the implications for
policy during this continuing period of economic volatility and austerity.

Putting the “where” in HIV care: Unpacking narratives of antiretroviral therapy adherence among HIV-Positive men who have sex with men
Augil Marie Q. Robles & Nico A. Canoy

This study explores the spatial constitution of adherence to antiretroviral therapy (ART) by recasting therapeutic landscapes (Gesler, 1992) and how it structures the exercise of expressive agency (Bowden, 2014). Engagement in antiretroviral therapy among HIV-positive men who have sex with men (MSM) is contextualized within the discursive-materiality of emplaced assemblages for HIV Care in the Philippines. Combining qualitative data from field visits and semi-structured interviews, three key spatial narratives were derived illustrating how adherence to ART unfolds in place: (a) an unwelcoming treatment hub, (b) an unsafe and safe home, and (c) a constraining workplace. The results illustrate the spatial, multilayered barriers to ART adherence proposing insights for the theorization of adherence as an emplaced process and the implications of using of place-based interventions in resource-limited countries beyond the discourse of free service and availability.

International Journal of Social Psychiatry

Lifetime experiences of gender-based violence, depression and condom use among female sex workers in Cameroon
Anna Abelson, Carrie Lyons, Michele Decker, Sosthenes Ketende, Iliassou Mfochive Njindam, Ghislaine Fouda, Flavien Ndonko, Daniel Levitt, Ubald Tamoufe, Serge Billong, Anne-Cecile Zoung-Kanyi Bissek & Stefan D Baral

In general populations, consistent data highlight the relationships among violence, HIV risk behavior and depression; however, these patterns are not well understood among female sex workers (FSWs). We examined the relationship between FSWs’ experiences with sexual violence and consistent condom use as a key HIV risk behavior and explored mental health as a potential mediator. In total, 2,165 FSWs were recruited via respondent-driven sampling in Cameroon in 2016. The women answered questions about violence, condom use and mental health. Inconsistent condom use with clients was reported by 23.5% of participants (508/2,165). Lifetime sexual violence was prevalent with 33.0% (713/2,163) of participants. Almost 50% (1,067/2,143) of respondents had some level of depression. Sexual violence was significantly associated with inconsistent condom use (adjusted risk ratio (aRR) 1.4, 95% confidence interval (CI) (1.2–1.6)). Of FSWs with no depression, 24.9% (267/1,071) reported sexual violence, versus 56.1% (32/57) of respondents with severe depression (p < .01). Severe depression significantly increased risk of condomless sex (aRR 1.8, 95% CI (1.3–2.6)); in mediation analysis, both sexual violence and severe depression remained significant predictors of condomless sex (aRR 1.4, 95% CI (1.2, 1.6) and aRR 1.7, 95% CI (1.2–2.4), respectively). Depression did not mediate the relationship between sexual violence and condom use. Sexual violence and depression are prevalent and independently associated with condom nonuse with clients among FSWs in Cameroon. Results highlight the need for interventions to address mental health as well as gender-based violence for FSWs.

Mental health stigma among people of color: An examination of the impact of racial discrimination
Sarah Krill Williston, Jennifer H Martinez, Tahirah Abdullah

The primary goal of this study was to examine the relations between racial discrimination experiences and different dimensions of mental health stigma among a diverse sample of people of color. Participants were recruited through blast emails at a large public university and completed an online survey (N = 205). Four linear regressions were completed predicting from recent racial discrimination experiences to (1) negative beliefs about mental health problems, (2) treatments, (3) treatment seeking and (4) anticipated stigma. Results indicated that recent racial discrimination experiences contributed unique variance in anticipated stigma from loved ones, as well as negative beliefs about mental health problems. Racial discrimination contributes to increased anticipated stigma and negative beliefs about mental health problems. Addressing the impact of racial discrimination as it influences these dimensions of mental health stigma is important to promote recovery among people of color.

Recovery education for people experiencing housing instability: An evaluation protocol
Anna Durbin, Grace Kapustianyk, Rosane Nisenbaum, Ri Wang, Tatiana Aratangy, Bushra Khan, Vicky Stergiopoulos

Recovery education centers (RECs) offer recovery supports through education rather than traditional health services. The Supporting Transitions and Recovery Learning Centre (STAR) in Toronto, Canada, is among the few that are internationally focused on individuals with histories of homelessness. Although research suggests that RECs positively impact participants, there is a paucity of rigorous studies and none address the engagement and impacts on homeless individuals. This protocol describes a realist-informed evaluation of STAR, specifically examining (1) if STAR participation is more effective in promoting 12-month recovery outcomes than participation in usual services for individuals experiencing housing instability and mental health challenges and (2) how STAR participation promotes recovery and other positive outcomes. This study uses a quasi-experimental mixed methods design. Personal empowerment (primary outcome) and recovery, housing stability, social functioning, health service use and quality of life (secondary outcomes) data were collected at baseline, and 6 and 12 months. Intervention group participants were recruited at the time of STAR registration while control group participants were recruited from community agencies serving this population after screening for age and histories of housing instability. Interviews and focus groups with service users and providers will identify the key intervention ingredients that support the process of recovery. From January 2017 to July 2018, 92 individuals were recruited to each of the intervention and control groups. The groups were mostly similar at baseline; the intervention group’s total empowerment score was slightly higher than the control group’s (M (SD): 2.94 (0.23) vs 2.84 (0.28), p = .02), and so was the level of education. A subset of STAR participants (n = 20) and nine service providers participated in the qualitative interviews and focus groups. This study will offer important new insights into the effectiveness of RECs, and expose how key REC ingredients support the process of recovery for people experiencing housing instability.

Attitudes to depression and psychiatric medication amid the enduring financial crisis in Attica: Comparison between 2009 and 2014
Marina Economou, Lily Peppou, Kyriakos Souliotis, Helen Lazaratou, Konstantinos Kontoangelos, Sofia Nikolaidi, Alexandra Palli, Costas N Stefanis

Only a handful of studies have explored the effect of the financial crisis on public attitudes to mental illness. This study examines changes in lay attitudes to depression and psychiatric medication between 2009 and 2014 in Attica region. Furthermore, it explored a potential interaction with employment status. Data were drawn from two surveys conducted in 2009 and 2014 using the same sampling procedure, interview mode, and survey instrument. Specifically, a random and representative sample of 586 people was recruited in 2009 and of 604 in 2014. Attitudes to depression were measured by the Personal Stigma subscale of the Depression Stigma Scale and attitudes to psychiatric medication by a self-constructed scale with good psychometric properties. Data collection occurred via telephone. There has been no overall change in lay attitudes to depression. Nonetheless, a positive change was recorded with regard to the belief that depression is a sign of personal weakness and a negative change with respect to people with depression being dangerous. Attitudes to psychiatric medication have worsened during the study period. Employment status was not found to interact with the survey year. Anti-stigma efforts should be tailored on counteracting the dangerousness stereotype, while they should prioritize targeting attitudes to psychiatric medication

PTSD as a consequence of past conflict experience, recent exposure to violence and economic marginalization in post-conflict contexts: A study from Nepal, Guatemala and Northern Ireland
Arne H Eide, Karin Dyrstad

Exposure to war and conflict increases the risk of mental health problems. Poor living conditions are known to negatively impact mental health. It is hypothesized that exposure to negative events after armed conflict interacts with past negative experiences, socioeconomic factors and current mental health problems. A cross-sectional survey was carried out in three contexts of previous internal armed conflict: Nepal, Guatemala and Northern Ireland. Three nationally representative samples were drawn, comprising a net sample of 3,229 respondents. Both recent negative events and past negative events linked to the previous conflicts were found to be associated with elevated risk of post-traumatic stress syndrome (PTSD). Economic marginalization and urban residency also contributed to current risk of PTSD. The results support the study hypothesis that both past and recent negative events in combination with economic marginalization contribute to explain current risk of PTSD. It is necessary both to improve living conditions more broadly and to establish and develop health services that have the capacity to screen, prevent and treat mental health problems also in poor contexts, in particular against a background of previous armed conflict.

Resilience and anxiety or depression among resettled Bhutanese adults in the United States
Kalpana Poudel-Tandukar, Genevieve E Chandler, Cynthia S Jacelon, Bhuwan Gautam, Elizabeth R Bertone-Johnson, Steven D Hollon

Resilience, or an individual’s positive response in managing life’s adversities, is of increasing interest in addressing the mental health disparities in refugees. Although the link between stressful life events and poor mental health is established, research on the role of resilience on the mental health of refugees is limited. This study assessed the association between resilience and anxiety or depression in resettled Bhutanese adults in Western Massachusetts. A cross-sectional survey was conducted among 225 Bhutanese (men: 113, women: 112) refugees aged 20–65 residing in Massachusetts. Resilience was measured with the 25-item Wagnild and Young’s Resilience Scale including two constructs as follows: a 17-item ‘personal competence’ that measures self-reliance, independence, determination, resourcefulness, mastery and perseverance and an 8-item ‘acceptance of self and life’ that measures adaptability, flexibility and a balanced perspective of life. Higher total scores indicate greater resilience. The Hopkins Symptom Checklist-25 was used to measure anxiety (10-item) and depression (15-item) with a cutoff mean score of ⩾1.75 for moderate to severe symptoms. Associations of resilience with anxiety or depression scores were assessed using multiple-linear and logistic regression analyses. The proportion of participants with above threshold anxiety and depression were 34.2% and 24%, respectively. Resilience was inversely associated with both anxiety (beta for 1 unit change in resilience scores: β = −0.026; p = .037) and depression (β = −0.036, p = .041). ‘Personal competence’ resilience was inversely associated with both anxiety (β = −0.041 p = .017) and depression (β = −0.058, p = .019), but ‘acceptance of self and life’ resilience was not. Participants with the highest tertile of resilience scores had a significantly decreased risk of anxiety (ORs (95% CI): 0.13 (0.04–0.40)) and depression (0.16 (0.04–0.60)). Higher resilience was associated with reduced anxiety and depression among Bhutanese with personal competence resilience accounting for most of the effects. These findings suggest the potential targets for mental-health intervention to improve resilience in refugees.

Concepts of mental disorders in the United Kingdom: Similarities and differences between the lay public and psychiatrists
Ben Butlin, Keith Laws, Rebecca Read, Matthew D Broome, Shivani Sharma

The lay public often conceptualise mental disorders in a different way to mental health professionals, and this can negatively impact on outcomes when in treatment. This study explored which disorders the lay public are familiar with, which theoretical models they understand, which they endorse and how they compared to a sample of psychiatrists. The Maudsley Attitude Questionnaire (MAQ), typically used to assess mental health professional’s concepts of mental disorders, was adapted for use by a lay community sample (N = 160). The results were compared with a sample of psychiatrists (N = 76). The MAQ appeared to be accessible to the lay public, providing some interesting preliminary findings: in order, the lay sample reported having the best understanding of depression followed by generalised anxiety, schizophrenia and finally antisocial personality disorder. They best understood spiritualist, nihilist and social realist theoretical models of these disorders, but were most likely to endorse biological, behavioural and cognitive models. The lay public were significantly more likely to endorse some models for certain disorders suggesting a nuanced understanding of the cause and likely cure, of various disorders. Ratings often differed significantly from the sample of psychiatrists who were relatively steadfast in their endorsement of the biological model. The adapted MAQ appeared accessible to the lay sample. Results suggest that the lay public are generally aligned with evidence-driven concepts of common disorders, but may not always understand or agree with how mental health professionals conceptualise them. The possible causes of these differences, future avenues for research and the implications for more collaborative, patient–clinician conceptualisations are discussed.

Greek university student’s attitudes and beliefs concerning mental illness and its treatment
Chrysi K Kaparounaki, Chrysoula A Koraka, Eleni S Kotsi, Anna-Maria P Ntziovara, Gerasimos C Kyriakidis, Konstantinos N Fountoulakis

Stigma concerning mental disorder is a widespread phenomenon concerning the beliefs and attitudes of the public toward mental patients with a significant negative impact on state policy and the outcome of the patients. The study included 1,363 students of the Aristotle University of Thessaloniki. The survey was based on an Internet-based electronic platform. The statistical analysis included analysis of variance (ANOVA) and Yates corrected chi-square test. Approximately, 87% of students responded that they know what mental disorder is, 70% were informed from the Internet, 30% consider mental patients responsible for their condition, more than 95% blame the way they were raised and almost 60% consider mental disorder to be heritable. Only a minority feel negatively with a mental patient around and close to 80% would socialize with them. More than 80% accept the need for psychiatric medication treatment but the opinion is split concerning compulsory treatment, and one-third consider medication to be harmful. The results of this study suggest that most students believe they know much about mental illness; however, overall their responses are contradictory. They reply with confidence although they are informed mainly by the media and the Internet in an unreliable way. A number of factors including gender, specific school or personal experience of mental disorder in the family seem to influence the result. A combined educational plus contact might be necessary to reduce stigma, since education alone seems to exert a weak effect.

Journal of the Royal Anthropological Institute

The trade in human liver lobes: bioviolence against organ sellers in Bangladesh
Monir Moniruzzaman

The rapid growth in organ transplantation has created an illicit trade in human organs. The kidney trade has flourished in the last few decades, but in the last few years this has been coupled with an emerging liver trade. This article examines the liver trade sourced from poor sellers in Bangladesh. Through ethnographic fieldwork, I investigate how a landless farmer and a village housewife both sell their liver lobes on the black market, and how the recipients undergo liver transplants in Bangladesh and India. I reveal that liver selling, like kidney selling, is primarily driven by the sellers’ debt. What is surprising, though, in this anthropological analysis is that microcredit, a Nobel Prize‐winning economic operation, has negatively contributed to organ selling in Bangladesh. I discover that the liver trade leads to tragic outcomes for both sellers and recipients: the sellers could not repay their loans by selling a liver lobe, while one of the recipients died just over a month after the surgery. I therefore argue that liver trade is advancing through a series of disturbing ironies, resulting in bioviolence, exploitation, and suffering for the vulnerable victims.

Medical Anthropology Quarterly

The Anthropology of Plastics: An Agenda for Local Studies of a Global Matter of Concern
Gauri Pathak, Mark Nichter

Anthropology has largely ignored plastics, even as they have emerged as the paradigmatic material—and problem—of our times. In this article, we make the case for an anthropology of plastics as a priority for environmental and medical anthropological research. Drawing from exploratory fieldwork in India, we briefly highlight the benefits and risks of different types of plastics, identify areas for anthropological investigations of human–plastic entanglements, and unpack major debates about plastic control. We recommend analyses that take into account the social life of plastics and the life cycle of plastic production, consumption, circulation, disposal, retrieval, and decomposition. We propose a facilitator role for anthropologists in bringing environmental NGOs and the plastic industry to the table to reduce the human and environmental health risks related to widespread reliance on plastics. Overall, we argue that anthropological analyses are urgently needed to address environmental and global health concerns related to plastics.

“Accept and Utilize”: Alternative Medicine, Minimality, and Ethics in an Indonesian Healing Collective
Nicholas J. Long

Cosmopolitan forms of alternative medicine have become very popular in contemporary Indonesia. Many healers have trained in an eclectic range of techniques, predicated on ontological claims so diverse that they call each other’s legitimacy into question. This article explores how a collective of alternative healers in central Java navigated the quandaries presented by such therapeutic eclecticism over a six‐year period. Healers’ engagement with, or indifference toward, the principles underpinning therapeutic efficacy fluctuated in ways that allowed them to surmount the dilemmas of Islamization, the changing demographic of their collective’s membership, and the threat of commercialization, thereby maintaining a medical landscape in which alternative healing was widely available and accessible. Transformations in their understanding, experience, and practice of healing should thus be understood in terms of how enduring ethical commitments are refracted through ongoing engagements with a changing social world.

(Un) Natural Grief: Novelty, Tradition and Naturalization in Israeli Discourse on Posthumous Reproduction
Ori Katz, Yael Hashiloni-Dolev

This article examines Israeli discourse on posthumous reproduction (PR) and the related cultural construction of “(un)natural” grief. Based mainly on an analysis of in‐depth interviews with family members who submitted a request for PR, we examine the regimes of justification used by supporters and opponents of this technology. With both sides using the notion of “nature” to support their claim, the dispute centers on whether PR constructs a new social expression of grief (and hence should be seen as unnatural) or is only a reflection of an age‐old grieving process (and is thus natural). We argue that by employing a twofold, novel/traditional justification, PR supporters aim to go one step further, from a symbolic continuity of the dead to a so‐called real one. This progression highlights the flexibility of the natural category at the intersection of technology and culture and the abandonment of such binary distinctions as life/death and nature/culture.

Global Ambitions: Evidence, Scale, and Child Well‐being in El Salvador
Tomas Matza

Experimental design and metrics have become increasingly common in international assistance, as donor agencies have demanded rigorous forms of evaluation and monitoring. This article contributes to debates about the effects of an “evidence‐based turn” on interventions and recipients by exploring two questions: What constitutes evidence when it comes to everyday practices of aid at global scales? How are the goals of assistance affected? The article draws on collaborative research with an NGO and a group of social scientists who seek to improve child well‐being in El Salvador. It shows how evidence‐making was polysemic and costly, ultimately impacting the NGO’s planned intervention. This outcome, I argue, was not a matter of poor planning, but reflects structural, evidence‐making demands placed on global assistance at this historical conjuncture. Discussions among stakeholders about the trade‐offs between evidence‐making and assistance is a possible future route through the challenges described in this article.

“There Is a Big Question Mark”: Managing Ambiguity in a Moroccan Maternity Ward
Jess Marie Newman

In Morocco, where extramarital sex and abortion are illegal, single mothers’ ambiguous status before the law inflects medical decision‐making. Leaky boundaries between the court and the hospital required doctors and administrators to work with multiple forms of documentation while anticipating external surveillance. Gaps between everyday experience and legalized forms of identity created confusion across multiple institutions. When discussing single mothers, hospital staff often spoke of “question marks” that flagged tensions between legibility and liability, disappearance and documentation. Managing question marks ramified surveillance and categorization. Ultimately, however, attempts to administratively resolve single mothers’ ambiguity created gaps and inconsistencies that allowed vulnerable patients to disappear from view.

Maintaining the Flow: Medical Challenges to Breastfeeding and “Risky” Bodies in Mexico
Jenna Murray de López

In this article, I discuss a case study from southeast Mexico that highlights conflicting ideas regarding what constitutes risk and illness in the context of breastfeeding and postpartum practices. On the one hand, doctors’ indeterminate and conflicting diagnoses about mother’s milk as a source of pollution is revealed as an act of moral pathology that frames young mothers as high risk. On the other hand, milk pollution is understood by women as an unwelcome yet temporary interruption that can be remedied through non‐allopathic intervention. As such, women can exert collective agency to overcome medicalized barriers to early breastfeeding and maintain established nurturing practices.

“Scribble Scrabble”: Migration, Young Parenting Latinas, and Digital Storytelling as Narrative Shock
Elizabeth L. Krause, Aline C. Gubrium

The nexus of migration and family offers a conjuncture to enrich understanding of teen pregnancy and parenting. This article draws findings from a project centered on participant‐produced new media to reveal how young mothers negotiate reproductive health disparities. We focus on young mothers’ experiences of migration and movement, captured in local vernacular through participants’ digital story depictions and follow‐up interviews. We argue that disparities link up with the single story of teen mothering, involve public shaming, continue hand‐in‐hand with institutional humiliation, and are exacerbated through migration and movement. To disrupt the normative notions that shadow young mothers, we take seriously the young women’s narratives. We theorize how the richness of stories and storytelling may serve as a potent intervention—a narrative shock—for articulating meanings and cultivating dignity for young mothers and their families, especially those who do not fit the sedentary and age biases of parenting ideals.

“Find that Balance:” The Impact of Cultural Consonance and Dissonance on Mental Health among Utah and Mormon Women
H. J. François Dengah II, Elizabeth Bingham Thomas, Erica Hawvermale, Essa Temple

Cultural consonance and religious participation are both associated with salutogenic mental health outcomes. Yet studies of religious and other cultural models must take into account multiple and conflicting cultural norms. In this article, we explore the consequences of trying to adhere to the oppositional cultural models of religious (Latter‐day Saint or Mormon) and secular American gender roles as perceived by college‐aged women at a Utah university. Using cultural consensus and cultural consonance analysis, we demonstrate that while conforming with one model may provide social and mental health benefits, striving for consonance with both results in increased perceived stress levels for Latter‐day Saints and nonmembers alike. Such cultural dissonance may be a contributing factor to the current mental health crisis among Utah youth. This work expands the theory of cultural consonance by examining it in the context of two incongruent lifestyles.

Medical Humanities

Essential(ist) medicine: promoting social explanations for racial variation in biomedical research (open access)
Iliya Gutin

Biomedical research has a long and complicated history
as a tool of oppression, exemplary of the racial science
used to legitimise and maintain racial hierarchies in the
USA and abroad. While the explicit racism and racial
inferiority supported by this research has dissipated
and modern methods of inquiry have increased in
sophistication and rigor, contemporary biomedical
research continues to essentialise race by distilling racial
differences and disparities in health to an underlying,
biogenetic source. Focusing on the persistence of
essentialism in an era of genomic medicine, this paper
examines the deep social origins and social implications
of the essentialist viewpoint in biomedicine and how
it relates to the broader construction of social and
scientific knowledge. Invoking Hacking’s ’looping
effects’ as a useful conceptual tool, I then demonstrate
how sociohistorical forces influence scientific and
medical research in producing evidence that favours
and legitimises a biological construction of race. I
extend the looping framework to consider a parallel
’louping’ process whereby applying a socially rooted
meaning to race in biomedical research results becomes
magnified to influence social norms and ideas about
race. As many biomedical researchers are motivated
by a desire to eliminate racial disparities in outcomes,
I argue that greater social acuity allows scientists to
avoid individualising and racialising health, challenge
preconceived assumptions about the meaning of racial
variation in health and medicine and thus promote and
strengthen a socioenvironmental focus on how to best
improve individuals’ and population health. Concluding
with a call for structural competency in biomedical
research, I suggest that empowering scientists to more
freely discuss sociostructural factors in their work allows
for the continued use of race in biological and medical
research, while social scientists and medical humanities
scholars stand to benefit from seeing their work
imbued with the cultural authority currently granted to
biomedicine.

The Participatory Zeitgeist: an explanatory theoretical model of change in an era of coproduction and codesign in healthcare improvement (open access)
Victoria Jane Palmer, Wayne Weavell, Rosemary Callander, Donella Piper, Lauralie Richard, Lynne Maher, Hilary Boyd, Helen Herrman, John Furler, Jane Gunn, Rick Iedema, Glenn Robert

Healthcare systems redesign and service
improvement approaches are adopting participatory
tools, techniques and mindsets. Participatory methods
increasingly used in healthcare improvement coalesce
around the concept of coproduction, and related
practices of cocreation, codesign and coinnovation.
These participatory methods have become the
new Zeitgeist—the spirit of our times in quality
improvement. The rationale for this new spirit of
participation relates to voice and engagement (those
with lived experience should be engaged in processes
of development, redesign and improvements),
empowerment (engagement in codesign and
coproduction has positive individual and societal
benefits) and advancement (quality of life and
other health outcomes and experiences of services
for everyone involved should improve as a result).
This paper introduces Mental Health Experience
Co-design (MH ECO), a peer designed and led
adapted form of Experience-based Co-design (EBCD)
developed in Australia. MH ECO is said to facilitate
empowerment, foster trust, develop autonomy,
self-determination and choice for people living with
mental illnesses and their carers, including staff at
mental health services. Little information exists about
the underlying mechanisms of change; the entities,
processes and structures that underpin MH ECO and
similar EBCD studies. To address this, we identified
eight possible mechanisms from an assessment
of the activities and outcomes of MH ECO and a
review of existing published evaluations. The eight
mechanisms, recognition, dialogue, cooperation,
accountability, mobilisation, enactment, creativity
and attainment, are discussed within an ’explanatory
theoretical model of change’ that details these and
ideal relational transitions that might be observed or
not with MH ECO or other EBCD studies. We critically
appraise the sociocultural and political movement in
coproduction and draw on interdisciplinary theories
from the humanities—narrative theory, dialogical
ethics, cooperative and empowerment theory. The
model advances theoretical thinking in coproduction
beyond motivations and towards identifying
underlying processes and entities that might impact
on process and outcome.

Vulnerability as practice in diagnosing multiple conditions (open access)
Lindsay-Ann Coyle, Sarah Atkinson

The paper contributes to contemporary understandings
of vulnerability by expanding their scope with an
understanding of vulnerability as generated through
institutionalised practices. The argument draws on
experiential accounts of navigating the practices of
diagnosis by people living with multiple conditions of
ill-health and disability. Vulnerability as a concept is used
widely across different domains and conveys a multitude of
meanings. Contemporary biomedicine, and its associated
health systems and services, understands vulnerability
mostly as inherent to particular physical and mental bodily
conditions that put people at risk of ill-health or emotionally
fragility. This may combine with a more epidemiological
understanding of vulnerability as the experience of certain
population groups subject to entrenched structural
inequalities. Philosophers and feminists have argued that
vulnerability is a universal experience of being human
while political commentators have explored its potential
as a resource for resistance and action. Diagnosis within
medicine and psychiatry has been the subject of extensive
social analysis, critique and activism. The paper draws
on first-hand experiential accounts collected through
face-to-face interviews with people living with multiple
conditions about their experiences of diagnosis, mostly at
the primary care level. We identify five aspects to diagnostic
practice that are harmful and exacerbate the experience
of vulnerability: temporal sequencing; diagnostic authority;
medical specialisation; strategic symptom selection; medical
isolation. However, these diagnostic practices are not
best understood only in terms of the power asymmetries
inherent to the medical consultation, but are embedded into
the very institution of diagnosis. The paper thus proposes
a combined approach to vulnerability that recognises it as
a universal condition of humanity but one that becomes
animated or amplified for some bodies, through their own
inherent incapacities or the external structures of inequality,
and through the practices of medicine as situated in
particular times and places.

What’s in it for the animals? Symbiotically considering ‘therapeutic’ human-animal relations within spaces and practices of care farming (open access)
Richard Gorman

Human-animal relations are increasingly imbricated,
encountered and experienced in the production of
medicine and health. Drawing on an empirical study
of care farms in the UK, this article uses the language
of symbiosis to develop a framework for critically
considering the relationships enrolled within interspecies
therapeutic practices. Care farming is an emerging
paradigm that aims to deploy farming practices as a
form of therapeutic intervention, with human-animal
relations framed as providing important opportunities
for human health. This article moves to attend to
multispecies therapeutic interventions and relationships
from a more-than-human perspective, drawing attention
to the often-troubling anthropocentrism in which such
practices are framed and performed. Attempting to
perform and realise human imaginations of ’therapeutic’
affects, spaces and relationships can rely on processes
that reduce animals’ own opportunities for flourishing.
Yet, the therapeutic use of other species does not have
to be forever anthropocentric or utilitarian. The article
explores whether relations between humans and animals
might result in a level of mutual proliferation of affective
capacities, reciprocally beneficial. These human-animal
entanglements highlight opportunities to think more
critically about how to practice interspecies relationships
and practices in ways that are less parasitic, and instead
framed more by attempts at producing opportunities for
mutualistic flourishing.

‘He’s my mate you see’: a critical discourse analysis of the therapeutic role of companion animals in the social networks of people with a diagnosis of severe mental illness (open access)
Helen Brooks, Kelly Rushton, Karina Lovell, Rebecca McNaughton, Anne Rogers

There is increasing recognition of the role pets play in
the management of mental health conditions. Evidence
suggests that pets promote social interaction and
provide secure and intimate relationships which support
the management of symptoms. This paper aimed to
extend this evidence by exploring the phenomenological
understanding of relationships and relationality with
companion animals as therapeutic agents in the context
of people’s wider social networks.
A qualitative study was undertaken incorporating 35
interviews with 12 participants with a diagnosis of
severe mental illness who identified a pet as being
important in the management of mental health.
Participants took part in three in-depth interviews
centred on ego network mapping over a 12-month
period (baseline, 6 and 12 months). A critical discourse
analysis examined therapeutic relationships with pets in
relation to mental health and compared these to other
types of support over time. Summative discourse analyses
were combined with a cross-case thematic analysis to
look for commonalities and differences across individuals.
Compared with interactions with other therapeutic
agents, relationships with pets were free from the
obligations and complexities associated with other
types of network members and provided an extension
and reinforcement to an individual’s sense of self which
militated against the negative experiences associated
with mental illness. Relationships with human network
members were more variable in terms of consistency and
capacity to manage demands (eg, network members
requiring support themselves) and the emotions of others
associated with fluctuations in mental health.
This study adds weight to research supporting the
inclusion of companion animals in the lexicon of mental
health self-management through the therapeutic
value attributed to them by participants within a
wide personal network of support. The findings point
to how consideration might usefully be given to
how relationships with companion animals can be
incorporated into healthcare planning and delivery

New Genetics & Society

Biomarkers and brains: situating dementia in the laboratory and in the memory clinic (open access)
Joanna Latimer, Alexandra Hillman

This paper provides a comparison of how genetic biomarkers are used (or not) in three contexts: clinic-based diagnostic work with people; lab-based research on mice and their marbles; and lab-based research on thrashing nematodes. For all the worldwide drive to find biomarkers that can be used in the detection of early, presymptomatic dementia, there is little research on how or when the association between biomarkers and a definitive disease are being made to “hold.” First, we show the disjuncture between the animal modeling that underpins laboratory attempts to stabilize genetic biomarkers and the paradigms that inform clinical diagnosis. Secondly, we develop this theme to show how in our third site, an epigenetics “worm” laboratory, neurodegenerative changes are explored as located in specific gene-environment interactions over time. We speculate whether such an enactment brings us closer to a notion of “situated biology,” to undercut possibilities of making genetic biomarkers of preclinical dementia hold.

Markers of biology and “being”: imaginaries of deterioration and the biological redefinition of Alzheimer’s disease
Julia Swallow

The Alzheimer’s disease (AD) research landscape is dominated by efforts to predict and prevent the condition. In clinical practice, it is difficult to establish normal aging from pathological cognitive deterioration and “imaginaries of deterioration” tied to “loss of self” take on a material form and impact assessment and diagnostic practice. Drawing on qualitative data gathered across a memory service in the UK, this paper captures practitioners’ reflections on the utility and potential impact of prediction and earlier detection. Practitioners maintain that this biological framing may reinforce uncertainties associated with sociocultural depictions of the condition and reify normative values concerning cognition and age; provoking questions concerning what kinds of values are produced by, and aligned with, bioscientific agendas. Overall, there emerges a paradox entangled in biologically redefining AD: purported precision and prediction on the one hand and increasing uncertainty on the other entwined with sociocultural imaginings of a future with AD.

Planning later life with dementia: comparing family caregivers’ perspectives on biomarkers with laypersons’ attitudes towards genetic testing of dementia prediction
Zümrüt Alpinar-Sencan, Leopold Lohmeyer & Silke Schicktanz

Predictive medicine presents opportunities to consider later life under conditions of illness, such as dementia. This paper examines how family caregivers (N = 27) assess the opportunity of prediction and early diagnosis of dementia for oneself based on their particular experience. Furthermore, it compares their attitudes with laypersons’ attitudes (N = 43) towards genetic testing of APOE. By this, we elaborate how much personal experience impacts anticipation and affects, but also moral attitudes towards predictive medicine. Differences in our settings do not allow for direct comparison, so our analysis focuses on multiple similarities in the assessments of predictive (non-genetic vs. genetic) testing. Groups’ reasoning showed also differences influenced mainly by personal experience. Family caregivers addressed more responsibility towards family and had more hopes into medical treatments. To cope with the disease, they expressed expectations to start with medicine and care decisions as early as possible. Laypersons, however, stressed self-determination more and expressed worries about the influence of the pharmaceutical industry by referring to unnecessary medication and, implicitly, the medicalization of aging.

Imagining the future of cell therapies: clinical trials, innovation and the intersection of clinical-academic and commercial visions
Ruchi Higham

This paper examines the role of clinical trials in regenerative medicine innovation, exploring how trials have contributed to translational challenges in the field. Using data from an ethnographic study of UK cell therapy trials I interrogate the institutional framework for clinical trials and the identity-making of trialists. This analysis uncovers a disconnect between a commercially-aligned regulatory framework and a clinical-academic identity apparent in the majority of current trialling activity. These different pathways appear to represent two distinct sociotechnical imaginaries for cell therapies; one which reflects the assumptions of commercial innovation and prioritizes economic success, and another which embodies the cultural expectations of academia and emphasizes the importance of clinical care. These two imaginaries operate in synergy to some extent but there are significant tensions between them. How and to what extent these tensions are reconciled is likely to determine both the long-term success and the future shape of the field.

Philosophy, Psychiatry, & Psychology

An Anthropological Perspective on Autism
Ben Belek

Autism spectrum conditions represent a broad range of behavioral, cognitive, and neurological atypicalities. As both a social and a medical category, autism is dynamic and unstable, and, although its usefulness is rarely contested, its ontological status is frequently under debate. Scholars who write about autism face the challenge of accepting the category as valuable without reifying it as one that corresponds unambiguously with a uniformly atypical brain structure. An approach to autism is, therefore, needed that acknowledges both its biological and social components and that embraces the inevitable contingency and mutability of knowledge about the condition. Drawing primarily on literature from anthropology, I argue that autism can be said to act in the world only insofar as it affords us a template, a system of meanings and significations with which to classify bodies, make sense of events and allow for an increasingly nuanced understanding of diverse behaviors, tendencies and motivations. Thus, the category of autism emerges from the shared experiences of those labeled autistic, but is wholly irreducible to them. A significant implication of this approach is a view of autism and autistic people as two conceptually distinct entities.

Science in Context

Educating physicians in seventeenth-century England
Jonathan Barry

The tension between theoretical and practical knowledge was particularly problematic for trainee physicians. Unlike civic apprenticeships in surgery and pharmacy, in early modern England there was no standard procedure for obtaining education in the practical aspects of the physician’s role, a very uncertain process of certification, and little regulation to ensure a suitable reward for their educational investment. For all the emphasis on academic learning and international travel, the majority of provincial physicians returned to practice in their home area, because establishing a practice owed more to networks of kinship, patronage and credit than to formal qualifications. Only when (and where) practitioners had to rely solely on their professional qualification to establish their status as young practitioners that the community could trust would proposals to reform medical education, such as those put forward to address a crisis of medicine in Restoration London, which are examined here, be converted into national regulation of medical education in the early nineteenth century, although these proposals prefigured many informal developments in medical training in the eighteenth century.

Science, Technology and Human Values

Rules versus Standards: What Are the Costs of Epistemic Norms in Drug Regulation?
Mattia Andreoletti, David Teira

Over the last decade, philosophers of science have extensively criticized the epistemic superiority of randomized controlled trials (RCTs) for testing safety and effectiveness of new drugs, defending instead various forms of evidential pluralism. We argue that scientific methods in regulatory decision-making cannot be assessed in epistemic terms only: there are costs involved. Drawing on the legal distinction between rules and standards, we show that drug regulation based on evidential pluralism has much higher costs than our current RCT-based system. We analyze these costs and advocate for evaluating any scheme for drug regulatory tests in terms of concrete empirical benchmarks, like the error rates of regulatory decisions.

Risky Technologies: Systemic Uncertainty in Contraceptive Risk Assessment and Management
Alina Geampana

Focusing on the controversial birth control pills Yaz and Yasmin, this article explores how debates about the safety of these drugs have materialized in risk evaluations and the management of technological risk. Drawing on in-depth interviews with stakeholders and content analysis of legal, medical, and regulatory documents, I highlight how professional contraceptive risk assessment is characterized by systemic uncertainty and doubt, resulting in increased responsibility for users themselves to manage the drugs’ potentially increased risks of venous thromboembolism. The analysis centers on three key areas in the assessment process that denote disagreement: risk measurement in postmarket surveillance data, the distinctiveness of the drugs’ benefits when compared to other contraceptive technologies, and the weighing of the risks and benefits against each other. While professionals negotiate uncertainty both in epidemiological research and in clinical practice, users are constructed as agents who should manage risk individually. Such processes are underlined by a diffusion of responsibility in the systemic management of contraceptive risk. This article suggests, more broadly, that medical technologies can be conceptualized as artifacts that are instrumental in the dispersion of risks.

Social Science & Medicine

Disentangling public preferences for health gains at end-of-life: Further evidence of no support of an end-of-life premium
Lise Desireé Hansen, Trine Kjær

In many countries, it has been publicly debated whether health gains for patients at end-of-life (EoL) should be valued higher than health gains for other patients. This has led to a range of stated preference studies examining the justification for an EoL premium on the basis of public preferences – so far with mixed findings. In the present study, we seek to extend this literature. We apply a simple stated preference approach with illustrative binary choices to elicit both individual and social preferences for several types of health gains. More specifically, we investigate whether health gains at EoL, resulting from either an improvement in quality of life (QoL) or life expectancy (LE) are valued differently from similarly sized health gains from preventive treatment and treatment of a temporary disease. Furthermore, we examine whether social preferences are affected by the age of beneficiaries. A web-based survey was conducted in 2015 using a random sample of 1047 members of the general public in Denmark. Overall, we do not find evidence to support an EoL premium compared to other health gains, neither when preferences are elicited from a social nor an individual perspective. Furthermore, our results demonstrate that the type of the health gain received matters to preferences for treatment at EoL with more weight given to gains in QoL than gains in LE. Finally, we find heterogeneity in preferences according to respondent characteristics, perspectives and age of beneficiaries.

Public acceptability of nudging and taxing to reduce consumption of alcohol, tobacco, and food: A population-based survey experiment
J.P. Reynolds, S. Archer, M. Pilling, M. Kenny, G.J. Hollands, T.M. Marteau

There is growing evidence for the effectiveness of choice architecture or ‘nudge’ interventions to change a range of behaviours including the consumption of alcohol, tobacco and food. Public acceptability is key to implementing these and other interventions. However, few studies have assessed public acceptability of these interventions, including the extent to which acceptability varies with the type of intervention, the target behaviour and with evidence of intervention effectiveness. These were assessed in an online study using a between-participants full factorial design with three factors: Policy (availability vs size vs labelling vs tax) x Behaviour (alcohol consumption vs tobacco use vs high-calorie snack food consumption) x Evidence communication (no message vs assertion of policy effectiveness vs assertion and quantification of policy effectiveness [e.g., a 10% change in behaviour]). Participants (N = 7058) were randomly allocated to one of the 36 groups. The primary outcome was acceptability of the policy. Acceptability differed across policy, behaviour and evidence communication (all ps < .001). Labelling was the most acceptable policy (supported by 78%) and Availability the least (47%). Tobacco use was the most acceptable behaviour to be targeted by policies (73%) compared with policies targeting Alcohol (55%) and Food (54%). Relative to the control group (60%), asserting evidence of effectiveness increased acceptability (63%); adding a quantification to this assertion did not significantly increase this further (65%). Public acceptability for nudges and taxes to improve population health varies with the behaviour targeted and the type of intervention but is generally favourable. Communicating that these policies are effective can increase support by a small but significant amount, suggesting that highlighting effectiveness could contribute to mobilising public demand for policies. While uncertainty remains about the strength of public support needed, this may help overcome political inertia and enable action on behaviours that damage population and planetary health.

How community and healthcare provider perceptions, practices and experiences influence reporting, disclosure and data collection on stillbirth: Findings of a qualitative study in Afghanistan
Aliki Christou, Ashraful Alam, Sayed Murtaza Sadat Hofiani, Mohammad Hafiz Rasooly, Adela Mubasher, Mohammad Khakerah Rashidi, Michael J.Dibley, Camille Raynes-Greenow

Quality concerns exist with stillbirth data from low- and middle-income countries including under-reporting and misclassification which affect the reliability of burden estimates. This is particularly problematic for household survey data. Disclosure and reporting of stillbirths are affected by the socio-cultural context in which they occur and societal perceptions around pregnancy loss. In this qualitative study, we aimed to understand how community and healthcare providers’ perceptions and practices around stillbirth influence stillbirth data quality in Afghanistan. We collected data through 55 in-depth interviews with women and men that recently experienced a stillbirth, female elders, community health workers, healthcare providers, and government officials in Kabul province, Afghanistan between October-November 2017. The results showed that at the community-level, there was variation in local terminology and interpretation of stillbirth which did not align with the biomedical categories of stillbirth and miscarriage and could lead to misclassification. Specific birth attendant practices such as avoiding showing mothers their stillborn baby had implications for women’s ability to recall skin appearance and determine stillbirth timing; however, parents who did see their baby, had a detailed recollection of these characteristics. Birth attendants also unintentionally misclassified birth outcomes. We found several practices that could potentially reduce under-reporting and misclassification of stillbirth; these included the cultural significance of ascertaining signs of life after birth (which meant families distinguished between stillbirths and early neonatal deaths); the perceived value and social recognition of a stillborn; and openness of families to disclose and discuss stillbirths. At the facility-level, we identified that healthcare provider’s practices driven by institutional culture and demands, family pressure, and socio-cultural influences, could contribute to under-reporting or misclassification of stillbirths. Data collection methodologies need to take into consideration the socio-cultural context and investigate thoroughly how perceptions and practices might facilitate or impede stillbirth reporting in order to make progress on data quality improvements for stillbirth.

U.S. combat veterans’ responses to suicide and combat deaths: A mixed-methods study
Pauline Lubens, Roxane Cohen Silver

Limited research has examined how combat veterans experience deaths of comrades to combat or suicide. We sought to investigate the process and identify factors that predict the level of grief among post-9/11 U.S. veterans. Using a mixed-methods study design during 2016–2017, U.S. combat veterans of the Iraq and Afghanistan conflicts who lost comrades to both combat and suicide (N = 28) participated in semi-structured interviews, and veterans who lost a comrade in combat or to suicide (N = 178) completed online surveys that assessed grief, combat exposure, unit cohesion, anger, posttraumatic stress symptoms (PTSS), and past diagnoses of PTSD and depression. Text analyses of interview transcripts revealed seven themes: 1) Suicide death is unexpected and can make acceptance of loss harder; 2) Combat death is expected and can ease acceptance of loss; 3) Combat death is heroic and can make acceptance of loss easier; 4) Brotherhood forged in combat intensifies the emotional response; 5) Guilt over the inability to prevent a comrade’s death makes acceptance harder; 6) Attribution of blame for a death creates anger; and 7) Detachment from the civilian world may make it more difficult to cope with comrades’ deaths. Regression analyses of survey data indicated: 1) suicide loss predicted non-acceptance of the loss; 2) mode of death moderated the association between unit cohesion and grief; 3) combat exposure, anger, closeness to the deceased, and having a past diagnosis of depression predicted the level of grief; and 4) combat exposure is a similarly strong predictor of grief and PTSS. Results highlight how veterans’ grief further delineates war’s toll. The mixed-methods design tells a rich story about a previously unexplored consequence of war. These findings have important public health implications because outcomes impact not only veterans but also their families and communities.

Personality trait predictors and mental well-being correlates of exercise frequency across the academic semester
Lara Kroencke, Gabriella M. Harari, Marko Katana, Samuel D. Gosling

Regular exercise is frequently recommended as a means of combating the negative effects of stress on mental health. But, among college students, exercise frequency remains below recommended levels. To better understand exercising behaviors in college students, we examined how exercise patterns change across an academic semester and how these changes relate to personality traits and mental well-being. We conducted two longitudinal experience sampling studies, using data from four cohorts of students, spanning four semesters (Fall 2015 – Spring 2017). In Study 1, a large sample of United States college students (cohort 1; N = 1126) reported the number of days they exercised and their levels of happiness, stress, sadness, and anxiety each week over the course of one academic semester (13 weeks). Study 2 (cohorts 2–4; N = 1973) was conducted to replicate our exploratory results from Study 1. Using latent growth curve modeling, we observed the same normative pattern of change across both studies: The average student exercised twice during the first week of the semester and showed consistent decreases in exercise frequency in following weeks. Across both studies, higher initial levels of exercise frequency at the start of the semester were consistently related to higher extraversion, higher conscientiousness, and lower neuroticism. Furthermore, exercise frequency and mental well-being fluctuated together after controlling for time trends in the data: In weeks during which students exercised more than predicted, they also reported being happier and less anxious. We contextualize the findings with regard to past research and discuss how they can be applied in behavior change interventions to promote students’ well-being.

Spatial access to sport facilities from the multiple places visited and sport practice: Assessing and correcting biases related to selective daily mobility
Samjhana Shrestha, Yan Kestens, Frédérique Thomas, Tarik El Aarbaoui, Basile Chaix

Studies investigating the association between spatial accessibility to environmental resources from the various places a person visits during daily activities and use of corresponding resources often do not account for potential biases related to selective daily mobility. This bias occurs when accessibility is also measured from places intentionally visited to access the resources of interest. The aim of this study was to examine associations between spatial accessibility to sports facilities from multiple places and sport practice while addressing the selective daily mobility bias. The second wave of the RECORD Cohort was used to examine the relationship between the spatial accessibility to sport facilities and the practice of three sport categories (swimming, racket, and team sports), using multilevel linear probability models (n = 5327 participants) adjusted for individual and contextual characteristics. Street network distance to the nearest sport facility was considered as a measure of spatial accessibility [from the residence; from the residence and workplace; from all visited locations (full activity space), biased; and from all locations excluded those visited for sports (truncated activity space), corrected]. The residential and residential-workplace accessibility to facilities was not associated with sport practice. The spatial accessibility to facilities from all places visited (full activity space) was associated with the practice of the three categories of sports (biased relationships). After correcting the bias (truncated activity space), the strength of the relationships was markedly reduced. An association remained only for swimming sports. This study underlines the need to account for selective daily mobility bias when determining spatial accessibility to resources from the various places visited. Such bias, if not addressed, may result in overestimated associations between spatial accessibility and use, leading to potentially erroneous conclusions in terms of planning.

Perceived discrimination and risk of preterm birth among Turkish immigrant women in Germany
Laura Scholaske, Annette Brose, Jacob Spallek, Sonja Entringer

Health disparities, including adverse birth outcomes, exist between Turkish immigrants and the autochthonous population in Germany. The state of research on the risk of preterm birth (PTB, defined as <37 weeks of gestation), the leading cause of infant mortality and morbidity, among Turkish immigrant women is mixed. Perceived discrimination is discussed in the context of health disparities related to migration. We examined whether PTB risk is also increased in Turkish immigrant women in Germany and whether perceived discrimination due to origin contributes to this risk. We selected a sample from the German Socio-Economic Panel (SOEP) study of German autochthonous and Turkish immigrant women who recently gave birth (between 2002 and 2016) (N = 2,525, incl. n = 217 Turkish immigrant women of which n = 111 completed an item on perceived discrimination). The included variables of central interest were immigrant status, perceived discrimination, gestational age, and socioeconomic situation. Logistic regression models indicated that PTB risk was significantly higher for Turkish immigrant women than autochthonous women (OR: 2.75, 95% CI [1.79–4.16]), even when adjusting for socioeconomic status. Within the subsample of Turkish immigrant women, perceived discrimination was related to a significantly higher PTB risk (OR: 4.91, 95% CI [1.76–15.06]). Our study provides evidence for a higher PTB risk in Turkish immigrant women compared to autochthonous women in Germany. Perceived discrimination may contribute to this higher risk. The findings represent an important first step towards developing targeted interventions to improve pregnancy and birth outcomes in minority groups.

How do actors with asymmetrical power assert authority in policy agenda-setting? A study of authority claims by health actors in trade policy
Belinda Townsend, Ashley Schram, Ronald Labonté, Fran Baum, Sharon Friel

How health advocates and industry actors attempt to assert their authority as a strategy of influence in policymaking remains underexplored in the health governance literature. Greater exploration of the kinds of authority sources used by health actors vis-à-vis market actors and the role ideational factors may play in shaping access to these sources provides insight into advocates’ efforts to exert influence in policy forums. Using the trade domain in Australia as a case study of the way in which the commercial determinants of health operate, we examined the different ways in which health, public interest and market actors assert their authority. Drawing on a political science typology of authority, we analysed 87 submissions to the Australian government during the Trans-Pacific Partnership negotiations. We identify four types of authority claims; institutional authority, derived from holding a position of influence within another established institution; legal authority through appeals to legal agreements and precedents; networked authority through cross-referencing between actors, and expert authority through use of evidence. Combining these claims with a framing analysis, we found that these bases of authority were invoked differently by actors who shared the dominant neoliberal ideology in contrast to those actors that shared a public interest discourse. In particular, market actors were much less likely to rely on external sources of authority, while health and public interest actors were more likely to appeal to networked and expert authority. We argue that actors who share strong ideational alignment with the dominant policy discourse appear less reliant on other sources of authority. Implications of this analysis include the need for greater attention to the different strategies and ideas used by industry and public health organisations in trade policy agenda-setting for health, which ultimately enable or constrain the advancement of health on government agendas.

Social Theory & Health

Bourdieu’s theory of fields: towards understanding help-seeking practices in mental distress
Sigita Doblytė

Employing Pierre Bourdieu’s sociology and his conceptual triad of field, habitus and capital, this article outlines a theoretical approach to empirically analyse help-seeking practices in mental distress. The framework helps to examine why the treatment gap in common mental disorders is wider in one setting than another and why some agents access healthcare more easily than others within the same setting, which may even drive to both over- and under-treatment resulting in inequities of access and poor use of resources. To understand help-seeking behaviour that varies across settings, time and conditions, it is suggested to relationally analyse how the field of mental healthcare as a structure of positions impacts access to healthcare; how mental structures that mirror cultural context and social conditions where they were acquired influence perceptions of access and, therefore, strategies of help seeking; and what historical genesis of both mental and objectified structures is.

Trying times: domestication of healthcare technologies amidst challenging dynamic contexts
Stephen Fox

There are many cases where technology domestication can be a comfortable experience. For example, there can be convenient supply of well-functioning consumer products, which are domesticated successfully into stable settings that are familiar and pleasing. By contrast, domestication of other technologies can be an uncomfortable experience. For example, there can be inconvenient supply of diverse healthcare products, which are not domesticated successfully into dynamic settings that are unfamiliar and far from pleasing. In this paper, challenging contexts for the supply and domestication of healthcare technologies are analysed in order to further develop four major constructs of Domestication Theory: appropriation, objectification, incorporation, and conversion. This leads to the definition of continua for these constructs that encompass the best of times and worst of times for technology domestication. These continua are related to biosocial structure and biosocial agency.

Patients’ experiential knowledge and expertise in health care: A hybrid concept analysis
Eva Marie Castro, Tine Van Regenmortel, Walter Sermeus, Kris Vanhaecht

Although the concept of experiential expertise is relatively new in modern health care services, policy, and research, it has profound implications for improving participation in healthcare. The absence of theoretical and conceptual clarity has led to poor understanding and miscommunication among researchers, health practitioners, and policy makers. The aim of this article is to present a concept analysis of experiential expertise and to explain its defining characteristics, applicability, and significance. A combination of Rodger’s evolutionary method combined with Schwartz-Barcott and Kim’s hybrid model was selected as a method for the analysis of the experiential expertise concept. This method combines theoretical (24 definitions) with empirical data analysis (17 interviews). Antecedents, attributes, and consequences are determined. A comprehensive definition is provided, and the interrelatedness between experiential expertise and related concepts was mapped. Experiential expertise is a complex process exceeding the boundaries of individual experiences. Its availability cannot be taken for granted. Using experiential expertise in health care can facilitate patient empowerment leading to improved quality of life and health care. The present study offers clarity by proposing a conceptual model that can assist researchers, policy makers, and health care professionals in facilitating implementations in practice.

Accountable care? An analysis of national reporting on local health and social care service integration
Sean Tunney, Jane Thomas

This paper analyses how the UK national press has covered local decision-making on options for the integration of health and social care. In England, as part of a major restructuring of health services, the UK government has devolved significant decisions on reorganising services to local areas. This increasing ‘localism’ in healthcare has been a global trend, albeit an uneven one. The article assesses the insights of Amitai Etzioni and others, as applied to national newspaper coverage of local decisions. It finds Etzioni’s analysis to be not fully supported. Following other journalism research on the NHS, we show that contentious points of wider public interest were little reported on, such as international corporate influence and the potential for fragmentation across a national health service.

Gaining public control on health policy: the politics of scaling up to universal health coverage in Uruguay
Xavier Ballart, Guillermo Fuentes

This study presents the health reform in Uruguay as an example of a country successfully gaining control over health policy and scaling up toward universal health coverage through a national insurance model. The study looks at the circumstances leading to the opening of the policy window and to the politics that made the passage of the reform possible. Evidence is mainly qualitative. The main findings relate to the role the state can play as an intelligent regulator and coordinator; the trade-off facing the governments since consolidating the private and third sector providers can strengthen the opposition to future policy changes; how medical and economic interests do not oppose reforms that preserve their autonomy, and how trade unions will not oppose reforms that simultaneously improve investment and working conditions in the public provider.

A metabolic self in contemporary Japan: a cultural reading
Genaro Castro-Vázquez

Framed by international concerns about obesity and overweight, Japanese officials highlight rising trends of men aged between 40 and 60 suffering from metabolic syndrome. Theoretically grounded in symbolic interactionism and the concept of ‘biopedagogy’ Wright (Biopolitics and the ‘obesity epidemic’ governing bodies, Routledge, London and New York, 2009), this article explores the symbolism attached to a metabolic self through a textual and iconographic analysis of 805 media reports and Internet sites produced between 2009 and 2017. Definition, guidance and gender are three axes that orient the analysis, whose outcomes suggest that from a definitional viewpoint a medical and ‘scientifically valid’ causal link between a metabolic self and disease cannot be established, but the origin of metabolic syndrome is allegedly ignorance and indolence, suggesting that metabolic syndrome is presocial. Guidance is largely underpinned by the formula dieting + exercise = bodyweight control, the retrieval of traditional Japanese food and the commodification of a metabo self. The case history of a married older man grappling with metabolic syndrome challenges the presociality thesis, and at the same time points up the feminisation of care. To conclude, the paper underscores that a metabo self has been largely scripted as a Westernised, commodified, weak-willed, male self largely depending on women.



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