Socio-cultural

and Ethnographic Research in Public Health

Jennifer J. Carroll, Ph.C., M.A. University of Washington jencarr2@uw.edu Presented at NaAonal University of Kyiv-Mohyla Academy 8 November, 2012

Research Interests
Medical Anthropology Drug use and addicAon Harm reducAon and prevenAon science Ontologies of biomedicine and public health Drug abuse and HIV-prevenAon eorts in Eastern Europe, especially Ukraine.

Research Interests
EsAmated prevalence
0.8% (2001) 1.5% (2007)

Among injecAon drug users (IDUs):

11% (2001) 17% (2007)

Prevalence among IDUs as high as 89% in some urban areas. (UNAIDS, 2008)

Questions epidemiologists might ask:

Which populaAons are most at risk for HIV-infecAon and why? What risk factors should be targeted in order to decrease HIV-transmission? How accurate is the monitoring and surveillance system, and how can it be improved?

Questions medical anthropologists might ask:

How do people decide to get tested for HIV? How does being female/queer/single/old/a villager/a mother/disabled/etc change how you and your illness are viewed, perceived, or understood? What strategies are people using to treat or manage their addicAon and/or other infecAous diseases? What does it mean to view addicAon as an illness?

Both approaches are necessary in order to understand patterns of disease in human populations

A Basic Public Health Question:

A. Smoking B. Lung cancer How can we determine whether risk factor A causes disease B?

Hills Criteria for Causality

Strength of Associa1on
The associaAon between A and B should be high. For example, lung cancer should be observed at a much higher rate in smokers than in non-smokers in order to provide evidence for causality.

Consistency
Did the associaAon between A and B appear repeatedly? Was it observed by dierent people in dierent places at dierent Ames?

Specicity
Is only A leading to only B? Are there mulAple factors involved?

Temporality
Does A always occur before B?
(Hill 1965)

Hills Criteria for Causality

Dose-Response Curve
Does more of A always lead to more of B?

Coherence
Would this causal relaAonship conict with any known facts about the natural history or biology of B?

Plausibility
Is there a plausible mechanism by which A could be causing B?

Experiment
Is there a way to test for B, given A, in a controlled or semi- controlled environment?

Analogy
Do we already know that things similar to A cause B or cause things similar to B. (Hill 1965)

Hills Criteria for Causality

Dose-Response Curve
Does more of A always lead to more of B?

Coherence
Would this causal relaAonship conict with any known facts about the natural history or biology of B?

Plausibility
Is there a plausible mechanism by which A could be causing B?

Behavioral and Structural Causes of Health Disparities

Social and anthropological research can contribute to more holisAc research on public health problems. It can ll the need for more detailed understandings of a populaAon in quesAon. It can help idenAfy the social and economic process that cause inequality and health dispariAes.

Behavioral and Structural Causes of Health Disparities

Medical anthropologists R. Chapman and J. Berggren (2005), ethnographers, in parAcular, can: 1. Generate new knowledge and new kinds of knowledge about people and communiAes. 2. Serve as cultural brokers, helping to represent the needs of under-represented persons to powerful naAonal and internaAonal actors. 3. Can provide alterna1ve bio-social models for explaining the health outcomes and dispari1es that we see today.

Example: Network Modeling

This is a compartment model. The rate of ow between the dierent compartments is modeled mathemaAcally. These models make key social and behavioral assump1ons

Ex: Ro = cd

Example: Network Modeling

Abu-Raddad et. al. (2008) built a model based on populaAon-wide data on the HIV epidemic in Kisumy, Keyna, and Yaounde, Cameroon. They calibrated the model (the populaAon at risk and the spread of the epidemic) to mimic the epidemic in this town.
blogs.vso.org.uk

Example: Network Modeling

Thats around 2500 lifeAme sexual partners.

Example: Network Modeling

Serial vs. Concurrent Partnerships

hnp://cptoolkit.hivsharespace.net/

Example: Network Modeling

Goodreau et. al. (2012) made a similar anempt at a model, but they built concurrent partnerships into the model, which was successful in predicAng current rates of infecAon 2 Partners: 4.4% of women 8.1% of men 3+ Partners: 0.6% of women 2.8% of men

Example: Social Relationships

In 2002, among homeless youth in San Francisco, California, women were 80% more likely to test posiAve for HepaAAs C than men. WHY? Bourgois et. al. (2004) invesAgated this unexplained phenomena ethnographically.

Example: Social Relationships

Gendered violence on the street - RomanAc RelaAonships: Provide physical safety for women Described and experienced in terms of love Men control injecAon, Riskier injecAon pracAces Jealousy and control dominate the relaAonship Women are monogamous, men are not.

My Current Research

Exploring the cultural and epidemiological realiAes of drug use, addicAon, and infecAous disease. Addic1on = fundamentally interesAng to explore Infec1ous Disease = explanaAon and resoluAon of health dispariAes within a local, cultural context

Health Disparities & Drug Use

Higher rates of HIV, TB, HepaAAs, abscess, sepsis. Disease passed primary through use of syringes and risky sexual pracAces. Why is it fair to call these health risks dispariAes? These diseases have a social cause, as well as a biological or epidemiological cause.

Harm Reduction Strategies

Needle Exchange Subs1tu1on Therapy

 What is Substitution Therapy?

 What is Substitution Therapy?

SubsAtuAon therapy consists of a daily dose of a legalized (medicalized) narcoAc, like buprenorphine or methadone dispensed at a locally sancAoned clinic or facility.

My Research Questions

Primary Why do people (addicts or drug users in parAcular) seek treatment for their addicAon or for infecAous diseases? Secondary What factors are shaping treatment seeking behaviors? What supporAve or protecAve factors exist that improve treatment and treatment success? What obstacles or risk factors exist that decrease treatment seeking or the success of treatment? How do addicts understand their own behaviors, which an epidemiologist or clinician would call treatment seeking? What do they think they are up to? (Geertz 1973, 9).

Guiding Social Theory

Explanatory Models of Disease (Kleinman 1988)
How we understand disease. How we idenAfy symptoms and explain the causes of disease. What we believe we should do about it and how we believe a disease should be treated.

Biopower and Governmentality (Foucault 1975; Lupton 1995)

Public health programs ask us to be responsible ciAzens. The goal is to discipline people into certain behaviors. These theories explain how dierent forms of social discipline work.

Structural Violence (Galtung 1969)

It is easier for some than others to reach their full potenAal. Social structure and social opportunity shape peoples lives.

Embodied Inequality (Kreiger 2005)

Explores the ways in which structural violence is directly responsible for health dispariAes between dierent populaAons.

Methods: Recruitment
PHASE 1 RECRUITMENT Convenience Sample: I talk to the people who are easiest to contact, regardless of how representaAve my sample is. This includes doctors, narcologists, nurses, TB paAents, methadone paAents. PHASE 2 RECRUITMENT Targeted Snowball Sampling: Move through the target populaAon (methadone paAents and un-treated drug users) through chains of recommendaAon. Especially work to target key and/or hard to reach groups.

Methods: Data Collection

Primary data collecAon: Semi-structured interviews Begin the interview with some general or broad quesAons. Adapt the interview script according to what the subject nds most interesAng or important. Let the subject control the direcAon of the interview. Instead of answering ques1ons based on your own thoughts and ideas about your research topic, let the subject teach you how they think about that topic.

How good interviews go bad

You put your subject in a situaAon that is not open or comfortable. You shut down your subject by asking leading or yes/no quesAons Your subject ips a script and you cant recognize it (Carr 2011).

Analysis: Grounded Theory

Goals: To nd systems of meaning, values, or behaviors that can help explain the panerns that we see. OR to generate new knowledge that we didnt realize we were missing before.

Analysis: Grounded Theory

Produce whole or parAal transcripts of interviews Read through them and idenAfy major themes and narraAves. Code the texts for these themes Build these themes into your next set of interviews. Test out your theory Rene your theory and your codes based on the new informaAon you have gathered. Re-code everything and repeat. The researcher remains constantly alert to emergent perspecAves that will change and develop his [sic] theory (Glaser and Straus 1967, 40).

Thank you!
I can be reached by email at jencarr2@uw.edu You can nd a copy of this presentaAon online at www.jenniferjcarroll.net

 Abu-Raddad, L. J. and I. R. Longin, Jr. 2008. No HIV stage is dominant in driving the HIV epidemic in Sub-Saharan Africa. AIDS 22(9): 1055-1061. Bourgois, P, B. Prince, and A. Moss. 2004. The everyday violence of hepaAAs C among young women who inject drugs in San Francisco. Human Organiza0on 63(3): 253-264. Carr, S. E. 2010. Scrip0ng addic0on: The poli0cs of therapeu0c talk and American sobriety. Princeton, NJ: Princeton University Press. Chapman, R. and J. Berggren. 2005. Radical contextualizaAon: ContribuAons to an anthropology of racial/ethnic health dispariAes. Health 9(2): 145-167. Foucault, M. 1975. The birth of the clinic: An archaeology of medical percep0on. New York: Vintage Books. Galtung, J. 1969. Violence, peace, and peace research. Journal of peace research 6(3): 167-191. Geertz, C. 1973. The interpreta0on of cultures. New York: Basic Books. Glaser, B. G. and A. L. Strauss. 1967. The discovery of grounded theory: Strategies for qualita0ve research. Chicago: Aldine Publishing Company. Goodreau, S. M., S. Cassels, D. Kasprzyk, D. E. Montano, A. Greek, and M. Morris. 2012. Concurrent partnerships, acute infecAon and HIV epidemic dynamics among your adults in Zimbabwe. AIDS and behavior 16(2):312-322. Hill, A. B. 1965. The environment and disease: AssociaAon or causaAon? Proceedings of the Royal Society of Medicine. 58: 295-300. Kleinman, A. 1988. The illness narra0ves: Suering, healing, and the human condi0on. Basic Books, Inc. Krieger, N. 2005. Embodying inequality: A review of concepts, measures, and methods for studying health consequences of discriminaAon. in Embodying inequality: Epidemiologic perspec0ves, N. Krieger, ed. New York: Baywood Publishing. Pp. 101-158. Lupton, D. 1995. The Impera0ve of Health: Public Health and the Regulated Body. London: Sage.