Vous êtes sur la page 1sur 33

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'“KyivDMohyla'Academy”'

Research+Interests+

Medical'Anthropology' Drug'use'and'addicAon' Harm'reducAon'and'prevenAon'science' Ontologies'of'biomedicine'and'public'health' Drug'abuse'and'HIVDprevenAon'efforts'in' Eastern'Europe,'especially'Ukraine.'

Research+Interests+

Research+Interests+ •   EsAmated'prevalence'' •   0.8%'(2001)'' •   1.5%'(2007)' •   Among'injecAon'drug' users'(IDUs):'' •  

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'HIVDinfecAon' and'why?'

' •  What'risk'factors'should'be'targeted'in'order'to' decrease'HIVDtransmission?' ' •  How'accurate'is'the'monitoring'and'surveillance' system,'and'how'can'it'be'improved?' '
'
•  What'risk'factors'should'be'targeted'in'order'to'
decrease'HIVDtransmission?'
'
•  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?'

Hill’s+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'nonDsmokers'in'order'to'provide'evidence'for'causality.''

Consistency*

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

Specificity*

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

Temporality*

Does'A'always'occur'before'B?'

''' (Hill'1965)'

'

Hill’s+Criteria+for+Causality+

Dose:Response*Curve*

Does'more'of'A'always'lead'to'more'of'B?'

Coherence*

Would'this'causal'relaAonship'conflict'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'semiD controlled'environment?'

Analogy*

Do'we'already'know'that'things'similar'to'A'cause'B'or'cause'

things'similar'to'B.' '

'''(Hill'1965)'

Hill’s+Criteria+for+Causality+

Dose:Response*Curve*

Does'more'of'A'always'lead'to'more'of'B?'

Coherence*

Would'this'causal'relaAonship'conflict'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'fill'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'underDrepresented'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+

Example:+Network+Modeling+ •   This'is'a' compartment*model ."" •   The'rate'of'flow'between'the'different'compartments'is' modeled'mathemaAcally.' •   These'models'make'key' social*and*behavioral* assump1ons* '

This'is'a'compartment*model."" The'rate'of'flow'between'the'different'compartments'is' modeled'mathemaAcally.' These'models'make'key'social*and*behavioral*

assump1ons*

'Ex:''R o '='βcd'

'

Example:+Network+Modeling+

Abu:Raddad*et.*al.*(2008)*

built'a'model'based'on'

populaAonDwide'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.''

Example:+Network+Modeling+ Abu:Raddad *et.*al.*(2008)* built'a'model'based'on' populaAonDwide'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

blogs.vso.org.uk'

Example:+Network+Modeling+

Example:+Network+Modeling+ That’s'around'2500' lifeAme'sexual'partners.''

That’s'around'2500'

lifeAme'sexual'partners.''

Example:+Network+Modeling+ That’s'around'2500' lifeAme'sexual'partners.''

Example:+Network+Modeling+

Serial'vs.'Concurrent'Partnerships'

Example:+Network+Modeling+ Serial'vs.'Concurrent'Partnerships' hnp:// cptoolkit.hivsharespace.net /'
Example:+Network+Modeling+ Serial'vs.'Concurrent'Partnerships' hnp:// cptoolkit.hivsharespace.net /'

hnp://cptoolkit.hivsharespace.net/'

Example:+Network+Modeling+

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:'

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+

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.'

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+

Example:+Social+Relationships+ Gendered'violence'on'the'street'D'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' •

Gendered'violence'on'the'street'D'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+

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'

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+

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”?' •  

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*

Harm+Reduction+Strategies+ Subs1tu1on*Therapy *

Subs1tu1on*Therapy*

Harm+Reduction+Strategies+ Subs1tu1on*Therapy *

+

What+is+Substitution+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.'

+ 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'different'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'people’s'lives.''

Embodied*Inequality*(Kreiger*2005)*

Explores'the'ways'in'which'structural'violence'is'directly' responsible'for'health'dispariAes'between'different'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'unDtreated' 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'finds'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+

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'“flips'a'

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'“flips'a' script”'and'you'can’t' recognize'it'(Carr'

2011).''

Analysis:+Grounded+Theory+

Analysis:+Grounded+Theory+ Goals:'To'find'systems' of'meaning,'values,'or' behaviors'that'can' help'explain'the' panerns'that'we'see.' OR'to'generate'new' knowledge'that'we' didn’t'realize'we'were' missing'before.''

Goals:'To'find'systems'

of'meaning,'values,'or'

behaviors'that'can'

help'explain'the'

panerns'that'we'see.'

OR'to'generate'new'

knowledge'that'we'

didn’t'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' Refine'your'theory'and'your'codes'based'on'the'new' informaAon'you'have'gathered.' ReDcode'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'find'a'copy'of'this'presentaAon'online'at'

www.jenniferjcarroll.net'

AbuDRaddad,'L.'J.'and'I.'R.'Longin,'Jr.'2008.'No'HIV'stage'is'dominant'in'driving'the'HIV'

epidemic'in'SubDSaharan'Africa.'AIDS%22(9):'1055D1061.'

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):'253D264.'

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):'145D167.'

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):'167D191.' 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):312D322.'

Hill,'A.'B.'1965.'The'environment'and'disease:'AssociaAon'or'causaAon?'Proceedings%of%the%

Royal%Society%of%Medicine.'58:'295D300.'

Kleinman,'A.'1988.'The%illness%narra0ves:%Suffering,%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.'101D158.'

Lupton,'D.'1995.%The%Impera0ve%of%Health:%Public%Health%and%the%Regulated%Body.'London:'Sage.'