The field of medical anthropology in Social Science & Medicine

Patient passports and vulnerability: Disjunctures in health policy instruments for people with rare diseases

Rare diseases have had a special status within European Union (EU) health policy since the late 1990s. According to key EU legal documents, rare disease patients are entitled to the same good quality care as others. These individuals are particularly vulnerable due to the "low prevalence" and "uniqueness" of their disease. To ensure that patients with rare disorders in Europe can access high-quality care in their respective countries, the Council of the European Union (2009) recommended that member states adopt plans or strategies for rare diseases. Poland adopted its first Plan for Rare Diseases in 2021. This article draws from bioethical and social science scholarship on vulnerability as well as ethnographic research that I conducted among people with rare metabolic diseases, their families, health professionals, and patient advocacy groups in Poland between 2016 and 2023. I examine instruments developed within healthcare policies that are tailored to rare diseases, notably the patient passport, which is a site of disjuncture (Appadurai, 1990) embedded in healthcare policies and practices tailored to people with rare diseases. I argue that although such instruments are meant to benefit patients, they almost exclusively focus on the patient's sick body and the needs of health professionals, who are unfamiliar with a given rare disease. Thus, these instruments may engender paternalistic practices and they may contribute to discrimination and stigmatization as well as to the datafication of health vulnerabilities. Furthermore, the focus on inherent vulnerability obscures its other "layers" (Luna, 2009, 2019) or "degrees" (Traianou and Hammersley, 2023).

The Five-Dimension Patient Experience Model and Its Applications in Healthcare Using the Example of Spinal Cord Injury and COPD

The need for a comprehensive patient experience model across healthcare sectors is crucial. This study introduces IEXP's five-dimension model: physical, emotional, social, cultural, and healthcare. Unlike hospital-centric frameworks, this model acknowledges holistic experiences, vital for chronic conditions. Applied to chronic obstructive pulmonary disease (COPD) and spinal cord injury (SCI), it showcases its adaptability. This model benefits healthcare, patient groups, pharmaceuticals, and medical tech, optimizing care, policy support, adherence, and patient-focused tech. Despite limitations and a chronic condition focus, the model adds value in shaping patient experience cross-sector.

Why don't Chinese college students seek help from the National Health Service (NHS)? Chinese college students' use of medical services in the UK

Background

International students have a lower utilization rate of the local medical service system for studying abroad, and it has been found that there may be multiple reasons behind this phenomenon. This study explores the usage of medical service systems by international students and the underlying logical factors through a study of the usage of National Health Service (NHS) of Chinese students in the UK.

Methods

To address the research questions, this study employed an online survey methodology that ran between 1st May and August 20, 2019 facing the Chinese students in the UK. A total of 1,050 questionnaires were distributed and 1,001 questionnaires were recovered, of which 977 contained valid responses (questionnaire response rate was 95.3 % and validity rate was 97.6 %). Before the questionnaire was designed and after it was issued, two focus group interviews were conducted to provide reliable and detailed information to inform the questionnaire design and to supplement the questionnaire survey data with more profound psychological qualitative data. The two focus groups consisted of 10 and 12 Chinese students studying in the UK and each lasted more than 3 h.

Results

The survey data showed that the medical services utilization rate of Chinese students in the UK is relatively low compared to UK residents and domestic Chinese students. Their decisions and behaviours around medical services usage in the UK are not significantly related to age, gender, and monthly income, but are instead related to their current education status, types of disease suffered, and information acquisition about the UK medical services before coming to the UK. When getting sick, in addition to seeking help from official medical services, Chinese students studying in the UK tend to self-diagnose and self-medicate; seeking help from social networks based on friendship and domestic relatives are also alternatives to accessing medical services.

Conclusion

Combining the theories of 'sick role' and 'illness experience', the decisions and behaviours related to medical services usage by Chinese students in the UK are significantly influenced by their understanding of medical services, which is socially and culturally learned in China. Understanding the perspective of the 'sick role' and the 'illness experience' of Chinese students may help to better think about how improvements can be made to their utilization rate of medical services and their health status during their studies in the UK. This study not only provides us with specific information and understanding on the usage of medical services for Chinese students in the UK, but the research results may also provide a reference for other similar research on the health and medical service use of other international students studying in the cross-cultural contexts.

Commercial milk formula marketing entry points: setting the course of infant and young child feeding trajectories

BACKGROUND

There is a limited understanding of the dynamic influences that shape infant and young child feeding (IYCF) decisions over time. We conducted an innovative qualitative study to reconstruct IYCF trajectories across early life course phases, in the context of the socioecological model (SEM) and the commercial determinants of IYCF.

METHODS

Women of different socioeconomic status were interviewed in two large metropolitan areas in Mexico. Our specific goal was to allow us to better understand if and how the commercial milk formula (CMF) marketing influenced breastfeeding decisions in a complex dynamic way involving the individual, relational, community and societal levels.

RESULTS

Hospitals, health professionals, and interactions with social media were key category entry points throughout the prenatal, perinatal, early infancy period and beyond. The CMF industry interfered by engaging a wide array of actors across the different layers of the SEM, most prominently the health care system and the workplace. Through its marketing strategies the CMF operates subconsciously and its messages are most effective when health institutions, health care providers, workplace spaces and social norms are weak in their support for breastfeeding.

CONCLUSIONS

The cases in our study highlight how, together with a weak breastfeeding counseling system, and health professionals who lack training in breastfeeding and normal infant behavior, lead to the opportunity for CMF marketing to shape infant feeding, and ultimately to the decision to feed formulas that some mothers were not planning to use and cannot afford.

A qualitative exploration of ultra-processed foods consumption and eating out behaviours in an Indonesian urban food environment

Background: Increased consumption of ultra-processed foods and drinks high in unhealthy fats, salt and sugar is a major driver behind rising non-communicable disease rates in Asia-Pacific. Urban residence is considered a risk factor for increased consumption of these products; yet, evidence on consumption behaviours and drivers from urban populations in the region remains limited. Aim: To understand perceptions and drivers of unhealthy fats, salt and sugar foods and drinks consumption and eating out behaviours in Yogyakarta city, Indonesia. Methods: In-depth qualitative data were collected through open-ended interviews and prolonged interactions in the local food environment, from a purposeful sample (N = 45) equally distributed across three urban communities. Data were analysed according to the principles of content analysis and following an iterative approach. Results: Despite showing high nutritional health awareness, respondents and their household members consumed ultra-processed foods high in unhealthy fats, salt and sugar regularly. Home consumption of these products was based primarily on economic considerations and convenience, but also related to attending requests from other family members, individual preferences and tastes, and social functions. Similarly, despite a reported preference for home-cooked traditional foods, several participants or their family members would frequently eat ready-made meals away from home, due to conflicting school or work commitments. Discussion: Results suggest that public health interventions focused on nutrition education among Indonesian communities should be coupled with measures addressing urban food environment characteristics that promote the consumption of unhealthy diets, be tailored to specific age groups, and leverage traditional food cultures.

Which Ethnography? Whose Ethnography? Medical anthropology's Epistemic Sensibilities Among Health Ethnographies

Medical anthropologists working in interdisciplinary teams often articulate expertise with respect to ethnography. Yet increasingly, health scientists utilize ethnographic methods. Through a comparative review of health ethnographies, and autoethnographic observations from interdisciplinary research, we find that anthropological ethnographies and health science ethnographies are founded on different epistemic sensibilities. Differences center on temporalities of research, writing processes, sites of social intervention, uses of theory, and analytic processes. Understanding what distinguishes anthropological ethnography from health science ethnography enables medical anthropologists - who sometimes straddle these two ethnographic modes - to better articulate their epistemic positionality and facilitate interdisciplinary research collaborations.

Adapting forensic case reporting to account for marginalization and vulnerability

Scholarship of forensic sciences has shown politicalization of human remains and potential biases in criminal investigations. Specifically, concerns have been raised regarding how forensic anthropology analysis and documentation may hinder identification processes or obfuscate other data. As part of this scholarship, some have suggested that forensic anthropologists expand their reporting to include broader public health and safety information as well as reconsider who should be included in reports of anthropological findings. In response to these burgeoning discussions, this piece provides examples of ways anthropologists may formulate reports that capture evidence of marginalization or structural vulnerability. Documentation of findings can occur in myriad formats, including, but not limited to, individual case reports, reports on population analyses from cases, collaborative end-of-year reporting conducted with other medicolegal professionals, and collaborative databasing. This piece provides various templates and suggestions for reporting this kind of data while encouraging further discussion on related merits and concerns.

Culture of vaccine acceptability or resistance: The curious case of Chile's COVID-19 vaccine rollout and anthropology's role in increasing vaccination uptake

Castillo and colleagues have described the curious case of Chile's COVID-19 vaccine rollout that how Chile has revealed a great success to vaccine a greater population. Interestingly, there are several factors responsible for that success and a lesson learnt for many countries who are lagging in this regard. Building on these authors arguments, I have defined the "culture of vaccine acceptability." In contrast, I explain the "culture of vaccine rejectability" based on own fieldwork in Pakistan. Chilean case has demonstrated how a culture is developed and influences vaccine uptake. For that, the countries lagging need to engage (medical) anthropologists as they are the culturologists.

Ethiopian immigrants with diabetes in Israel: Oscillating between two narratives

AIM

The purpose of this project was to examine the role of cultural differences in shaping the management of diabetes among Ethiopian immigrants living in Israel.

METHODS

A qualitative, in-depth study involved semistructured interviews with 16 Ethiopian immigrants with diabetes living in Israel. The interviews were audio-recorded, transcribed and translated into Hebrew, if necessary. The authors each identified themes in the responses and then through discussion came to a consensus about the most significant ones and how to categorize them.

RESULTS

A main theme was revealed structuring the participants' perception of diabetes: an oscillation between a familiar narrative, associated with traditional life in Ethiopia, and a foreign one. Five additional subthemes were also identified as an oscillation about the causes of disease, between collectivism and individualism, between accessible food and a balanced diet, between relying on bodily sensations and prescribed treatment and between culturally oriented and translated knowledge.

CONCLUSION

The participants understood that they could be adversely affected both by the changes in lifestyle following their move and by adhering to the traditional norms. They agreed that professional liaisons and peers who have successfully managed their diabetes could help provide a bridge between the narratives.

"We've all got the virus inside us now": Disaggregating public health relations and responsibilities for health protection in pandemic London

The COVID-19 pandemic has disproportionately impacted ethnic minorities in the global north, evidenced by higher rates of transmission, morbidity, and mortality relative to population sizes. Orthodox Jewish neighbourhoods in London had extremely high SARS-CoV-2 seroprevalence rates, reflecting patterns in Israel and the US. The aim of this paper is to examine how responsibilities over health protection are conveyed, and to what extent responsibility is sought by, and shared between, state services, and 'community' stakeholders or representative groups, and families in public health emergencies. The study investigates how public health and statutory services stakeholders, Orthodox Jewish communal custodians and households sought to enact health protection in London during the first year of the pandemic (March 2020-March 2021). Twenty-eight semi-structured interviews were conducted across these cohorts. Findings demonstrate that institutional relations - both their formation and at times fragmentation - were directly shaped by issues surrounding COVID-19 control measures. Exchanges around protective interventions (whether control measures, contact tracing technologies, or vaccines) reveal diverse and diverging attributions of responsibility and authority. The paper develops a framework of public health relations to understand negotiations between statutory services and minority groups over responsiveness and accountability in health protection. Disaggregating public health relations can help social scientists to critique who and what characterises institutional relationships with minority groups, and what ideas of responsibility and responsiveness are projected by differently-positioned stakeholders in health protection.

Discrimination as a Moderator of the Effects of Acculturation and Cultural Values on Mental Health Among Pregnant and Postpartum Latina Women

It is important to consider how identity, culture, and social adversity influence maternal mental health among Latina women both because this community faces unique cultural stressors and also because factors that undermine women's mental health during pregnancy and postpartum could have injurious consequences that cascade across generations. This study uses data from a questionnaire administered to Latina pregnant and postpartum women in Southern California, examining cultural orientation, discrimination, and mental health. Results demonstrate mental health benefits for both American and Latino cultural orientations, but the latter's benefit of lower anxiety was only apparent with high discrimination. American and Latino cultural values systems had opposite relationships with depression, with the latter protective and also positively associated with happiness. More traditional gender roles values were associated with greater perceived stress and lower happiness. Different aspects of familism had opposite effects as obligation was associated with less anxiety and referent (defining oneself communally with kin) with more. Results suggest that social adversity and cultural identity and values influence maternal psychology. This study makes a unique contribution by integrating anthropological and biopsychosocial methods and theories towards addressing an issue of public-health importance.

One Health Perspectives on New Emerging Viral Diseases in African Wild Great Apes

The most recent emerging infectious diseases originated in animals, mainly in wildlife reservoirs. Mutations and recombination events mediate pathogen jumps between host species. The close phylogenetic relationship between humans and non-human primates allows the transmission of pathogens between these species. These pathogens cause severe impacts on public health and impair the conservation of habituated or non-habituated wild-living apes. Constant exposure of great apes to human actions such as hunting, deforestation, the opening of roads, and tourism, for example, contributes to increased interaction between humans and great apes. In spite of several studies emphasizing the risks of pathogen transmission between animals and humans, outbreaks of the reverse transmission of infectious agents threatening wildlife still occur on the African continent. In this context, measures to prevent the emergence of new diseases and conservation of primate species must be based on the One Health concept; that is, they must also ensure the monitoring of the environment and involve political and social aspects. In this article, we review and discuss the anthropological aspects of the transmission of diseases between people and wild primates and discuss new anthropozoonotic diseases in great apes in Africa from studies published between 2016 and 2020. We conclude that the health of great apes also depends on monitoring the health of human populations that interact with these individuals.

Living in opposition: How women in the United States cope in spite of mistrust of federal leadership during the pandemic of Covid-19

International research collaborators conducted research investigating sociocultural responses to the Covid-19 pandemic. Our mixed methods research design includes surveys and interviews conducted between March and September of 2020 including 249 of 506 survey responses and 18 of 50 in-depth, exploratory, semi-structured interviews with self-defined politically left-leaning women in the United States. We employ a sequential design to analyze statistical and qualitative data. Despite international data suggesting that trust in federal governments reduces anxiety, women who did not trust and actively opposed the Trump administration reported lower levels of anxiety than expected. Results indicate reliance on and development of new forms of connection that seem to mitigate symptomatic anxieties when living in opposition. Women living in opposition to the leadership of the federal government use and develop resources to help them cope. Research on coping strategies and mental health and anxiety during crisis can inform recommendations for ways to support and strengthen sense of coherence during tumultuous times.

Dietary health perceptions and sources of nutritional knowledge in an urban food environment: a qualitative study from Indonesia

OBJECTIVE

To investigate dietary health understandings, healthy foods access perceptions and the main sources of nutritional knowledge of residents in three urban communities of varying socio-economic make-up.

DESIGN

An ethnographic approach to primary qualitative data collection, involving frequent visits to study areas over 4 months and in-depth interviews. Interviews were recorded, transcribed verbatim and analysed through an iterative approach.

SETTING

Yogyakarta, Indonesia.

PARTICIPANTS

A purposive sample of 45 participants divided equally among the 3 communities. Participants were mostly female (93 %), aged between 27 and 75 years (mean 47·7) and largely identified as the person responsible for household food-related decisions (93 %).

RESULTS

Three overarching themes emerged: (i) dietary health understandings; (ii) healthy foods access perceptions and (iii) sources of nutritional knowledge. Participants employed multifaceted conceptualisation of dietary health. Most identified healthy foods with traditional plant-based foods, inexpensive and locally available from multiple sources. Thus, all participants perceived healthy foods as highly available in the local environment and most (80 %) as affordable. Reported affordability issues referred to specific foods (particularly animal source products) and were independent of income levels. Participants acquired nutritional knowledge from multiple sources, including many community-based initiatives. These were overall perceived as useful, but also as presenting some limitations.

CONCLUSIONS

The variety in dietary health understandings reported by study participants, and their high perceptions of healthy foods availability in the local environment reinforce the idea that individual- and food environment-level determinants of nutritional behaviours are highly contextual.

The wound that closes doors: Lived experiences and complexities of injection-related injuries and infections among people who inject drugs through an ethnographic lens

BACKGROUND

Besides HIV, people who inject drugs (PWID) experience other biomedical adversities, including injection-related injuries and infections. Yet, they are often inadequately addressed due to the prioritisation of HIV-related issues. This article explored the risk environment and socio-structural adversities of PWID living with injection-related injuries and infections, as well as existing management and treatment challenges of these conditions in harm reduction interventions.

METHODS

We undertook an ethnographic study from April 2018 to December 2019 in selected areas of Dhaka, Bangladesh. This component of the study involved 2500 hours of observations and informal conversations, 35 in-depth interviews and five focus group discussions with PWID experiencing injection-related injuries and infections. We also performed seven key-informant interviews with service providers and clinical experts. We applied thematic analysis and used various theoretical social scientific conceptualisations to analyse the relationship between the biomedical realities and socio-structural vulnerabilities of PWID.

RESULTS

Our findings indicated that PWID's physical, legal and socio-economic environments predisposed PWID to risky practices which ultimately precipitated injection-related injuries and infections. These injection-related injuries and infections consequently displaced them in spheres of social exclusion, stigmatisation, physical pain and disability and, hence, fueled their feelings of distress and despondence. Our findings also presented limitations in the management strategy of these injection-related injuries and infections. Specifically, service providers misconstrued all these complexities as "abscesses", thus applying a simplistic "one-size-fits-all" approach without accounting for the diversity of these complexities. This led to a paucity of tailored care and management approaches which could precipitate unfavourable treatment outcomes, such as chronic and complicated cases with antibiotic resistance.

CONCLUSION

Injection-related injuries and infections nestled PWID within various prongs of biomedical and socio-structural adversity, without viable and targeted treatment modalities. Thus, it is integral to nurture a multifaceted harm reduction intervention tailored to their biomedical and socio-structural needs.

Decolonizing Indigenous health: Generating a productive dialogue to eliminate Rheumatic Heart Disease in Australia

In common with colonized Indigenous people worldwide, many Australian Aboriginal people experience inequitable health outcomes. While the commitment and advocacy of researchers and health practitioners has resulted in many notable improvements in policy and practice, systemic and structural impediments continue to restrain widespread gains in addressing Indigenous health injustices. We take Rheumatic Heart Disease (RHD), a potent marker of extreme health inequity, as a case study, and critically examine RHD practitioners' perspectives regarding the factors that need to be addressed to improve RHD prevention and care. This study is an important explanatory component of a broader study to inform new clinical practices, and health system strategies and policies to reduce RHD. A decolonising, critical medical anthropology (CMA) analysis of findings from 22 RHD practitioner in-depth interviews conducted in May 2016 revealed both practitioners' perceptions of health system shortcomings and a sense of hopelessness and powerlessness to transform existing health system inequities, the negative impacts of which were subsequently confirmed in a separate study of RHD patients' lived realities. We reveal how biomedical dominance, normalized deficit discourses and systemic racism influence the current policy and practice landscape, narrowing the intercultural space for productive dialogue and reinforcing the conditions that cause disease. To counter biomedical approaches that contribute to existing health inequities in health care, we recommend localized, strength-based, community-led research projects focused on actions that use critical decolonizing social science approaches to achieve system change. We demonstrate the importance of integrating biological and social sciences approaches in research, education/training, and practice to: 1) be guided by Indigenous strengths, knowledges and worldview, and 2) adopt a critical reflexive stance to examine systems, structures and practices. Such an approach facilitates productive cross-cultural dialogue and social transformation; providing direction and hope to practitioners, enhancing their knowledge, skills and capacity and improving Aboriginal health outcomes.

Analytic autoethnography of familial and institutional social identity construction of My Dad with Alzheimer's: In the emergency room with Erving Goffman and Oliver Sacks

This paper analyzes variable social identity construction for my Dad over his last two years, within his family, and then within several institutions, before he died of Alzheimer's Disease (AD). This article makes epistemic and methodological contributions to research on persons with AD by using analytic autoethnography and long-term ethnographic case development to trace processes by which my Dad's evolving social identity was constructed -- and increasingly socially constructed -- as his memory became more impaired and he moved from home into several institutions. It analyzes how our family resisted his conversion into an "AD patient" - the stigmatized sum of his symptoms - but engaged in what felt like Goffmanian betrayals to care for him. The paper recognizes the value and need to fight the image of AD as social death in research, the medical system, and popular understanding, but proposes a family Memory-Relationship self to conceptually capture the trauma many families feel as AD increasingly impairs the loved one with AD and leads to their death (unless they die of something else first). My Dad's placement in five institutions in six months created awful natural experiment-like leverage, because he was alternatively constructed in institutions as a legally competent adult, a dangerous patient, and an AD patient, and often responded correspondingly.

Investigating into the critical factors supporting healthy independent longevity: A proposition of a conceptual model with measurements during and beyond COVID-19 pandemic

This study investigated the factors that support the elderly citizens' perceived healthy independent longevity during and beyond the COVID-19 pandemic. The Structural Equation Modeling was conducted with the 1607 dataset collected from Japan to validate a proposed model with six antecedent factors. It has been found that "Town vibrancy" and "Mobility and transportations" have the most significant impact, whereas "Health and welfare policies" and "Community bonding" have a relatively lower impact on their perceived healthy longevity. The study has provided a conceptual model with measurements for further discussions in the field of study.

Tobacco use and cessation in the context of ART adherence: Insights from a qualitative study in HIV clinics in Uganda

Sub-Saharan Africa carries a disproportionate burden of human immunodeficiency virus (HIV). Tobacco use amongst people living with HIV is higher than in the general population even though it increases the risk of life-threatening opportunistic infections including tuberculosis (TB). Research on tobacco use and cessation amongst people living with HIV in Africa is sparse and it is not clear what interventions might achieve lasting cessation. We carried out qualitative interviews in Uganda in 2019 with 12 current and 13 former tobacco users (19 men and 6 women) receiving antiretroviral therapy (ART) in four contrasting locations. We also interviewed 13 HIV clinic staff. We found that tobacco use and cessation were tied into the wider moral framework of ART adherence, but that the therapeutic citizenship fashioned by ART regimes was experienced more as social control than empowerment. Patients were advised to stop using tobacco; those who did not concealed this from health workers, who associated both tobacco and alcohol use with ART adherence failure. Most of those who quit tobacco did so following the biographical disruption of serious TB rather than HIV diagnosis or ART treatment, but social support from family and friends was key to sustained cessation. We put forward a model of barriers and facilitators to smoking cessation and ART adherence based on engagement with either ‘reputation’ or ‘respectability’. Reputation involved pressure to enjoy tobacco with friends whereas family-oriented respectability demanded cessation, but those excluded by isolation or precarity escaped anxiety and depression by smoking and drinking with their peers.

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People living with HIV in Uganda hid their tobacco use from health workers.

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The experience of tuberculosis was the most common trigger to quit smoking.

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Engagement with ‘respectable’ masculinity promoted smoking cessation.

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Engagement with ‘reputational’ masculinity made it hard to quit.

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This model has wider applicability for antiretroviral therapy adherence.

Linking humans, their animals, and the environment again: a decolonized and more-than-human approach to "One Health"

This article considers a broad perspective of "One Health" that includes local and animal knowledge. Drawing from various colonial efforts to link human, animal, and environmental health, it first shows that the current "One Health" initiative has its roots in colonial engagement and coincides with a need to secure the health of administrators (controlling that of local populations), while pursing use of resources. In our contemporary period of repeated epidemic outbreaks, we then discuss the need for greater inclusion of social science knowledge for a better understanding of complex socio-ecological systems. We show how considering anthropology and allied sub-disciplines (anthropology of nature, medical anthropology, and human-animal studies) highlights local knowledge on biodiversity as well as the way social scientists investigate diversity in relation to other forms of knowledge. Acknowledging recent approaches, specifically multispecies ethnography, the article then aims to include not only local knowledge but also non-human knowledge for a better prevention of epidemic outbreaks. Finally, the conclusion stresses the need to adopt the same symmetrical approach to scientific and profane knowledge as a way to decolonize One Health, as well as to engage in a more-than-human approach including non-human animals as objects-subjects of research.

Security from above and below: A critical ethnography of the health response to violence against women in Timor-Leste

International advocacy and evidence have been critical for shifting the pervasive issue of violence against women onto the health agenda. Guidelines and training packages, however, can be underpinned by Western principles of responding to individual survivors of violence and availability of specialist referral services, which may not be available in many countries. As Timor-Leste and other nations begin to build their health system response to violence against women, it is important to understand the current practices of health providers and the broader sociocultural context of providing care to survivors of violence. During 11 months in the field (February-December 2016), we conducted qualitative interviews with 48 midwives and community leaders in three municipalities in Timor-Leste. The findings reveal that midwives engage at both the individual and collective levels, providing medical care, advice and moral support to survivors of violence as well as gathering support for women within families and communities. Midwives therefore navigate both formal and informal spaces as they respond to domestic and sexual violence. In doing so, they are influenced by their own experiences as women, as health providers imbued with authoritative knowledge, and as part of the wider sociocultural system. We argue that while much progress has been made in frameworks for health systems responding to survivors of violence, more work needs to be done to understand how to support health providers in low- and middle-income countries as they engage with perpetrators, families and communities. There is a need for further discussion of how health systems can address the issue of domestic and sexual violence as a collective social problem, while foregrounding the needs and rights of those experiencing violence. This research has implications for the content of guidelines and training, and importantly, for developing mechanisms to deal with complex social issues within local health services.

Explaining the social gradient in smoking and cessation: the peril and promise of social mobility

Smoking in high-income countries is now concentrated in poor communities whose relatively high smoking prevalence is explained by greater uptake but above all by lower quit rates. Whilst a number of barriers to smoking cessation have been identified, this is the first paper to situate cessation itself as a classed and cultural practice. Drawing on ethnographic research carried out in a working-class community in the North of England between 2012 and 2015, I theorise smoking cessation as a symbolic practice in relation to the affective experience of class and social mobility. I show that ambivalence about upward mobility as separation and loss translated into ambivalence about smoking cessation. The reason for this was that the social gradient in smoking operated dynamically at the level of the individual life course, i.e. smoking cessation followed upward mobility. A serious health problem was an appropriate reason to quit but older women continued to smoke despite serious health problems. This was linked to historical gender roles leading to women placing a low priority on their own health as well as the intergenerational reproduction of smoking through close affective links with smoking parents.

Nicotine addiction as a moral problem: Barriers to e-cigarette use for smoking cessation in two working-class areas in Northern England

Tobacco use in high-income countries correlates with socio-economic disadvantage, but although switching to electronic cigarettes could be a safer alternative, little is known about barriers to use. Drawing on eighteen months of data collection in two areas of Northern England in 2017/18 including ethnography and interviews with 59 smokers and e-cigarette users, I show that concern about continued nicotine addiction either deterred working-class smokers from switching to e-cigarettes or dictated the conditions of their use. Research participants were unhappy about addiction both as loss of control experienced as moral failure and as neglect of financial responsibilities i.e. role performance failure in relation to family responsibilities, or what I call ‘thrift as care’. They reduced the moral burden of addiction by lowering nicotine content, rejecting pleasure and minimising expenditure. They chose the cheapest possible tobacco, switched from combusted tobacco to cheaper e-cigarettes and bought cheap e-cigarettes and liquids. For working-class smokers, minimising spend on what they perceive negatively as addiction may be a greater moral concern than reducing health risk. I conclude that ensuring that vaping is significantly cheaper than smoking may be key to addressing health inequalities linked to tobacco use.

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Working-class smokers avoided e-cigarettes because of concern about addiction.

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Those who did switch preferred a medical to a recreational model of use.

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Users reduced nicotine content, minimised spending and avoided exotic flavours.

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Failure of willpower and role performance (thrift as care) created addiction shame.

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Ensuring that vaping is cheaper than smoking is key to harm reduction.

On allegations of invasive species denialism

Science denialism retards evidenced-based policy and practice and should be challenged. It has been a particular concern for mitigating global environmental issues, such as anthropogenic climate change. But allegations of science denialism must also be well founded and evidential or they risk eroding public trust in science and scientists. Recently, 77 published works by scholars, scientists, and science writers were identified as containing invasive species denialism (ISD; i.e., rejection of well-supported facts about invasive species, particularly the global scientific consensus about their negative impacts). We reevaluated 75 of these works but could find no examples of refutation of scientific facts and only 5 articles with text perhaps consistent with one of the 5 characteristics of science denialism. We found, therefore, that allegations of ISD were misplaced. These accusations of science denialism may have arisen because invasion biology defines its subjects-invasive species-based on multiple subjective and normative judgments. Thus, more than other applied sciences its consensus is one of shared values as much as agreed knowledge. Criticisms of invasion biology have largely targeted those subjective and normative judgments and their global imposition, not the knowledge on which the discipline is based. Regrettably, a few invasion biologists have misinterpreted the critique of their values-based consensus as a denial of their science when it is not. To make invasion biology a more robust and widely accepted science and to avoid unnecessary misunderstandings and conflicts, invasion biologists could be more accepting of perspectives originating from other disciplines and more open to values-based critique from scholars and scientists outside their field. This recommendation applies to all conservation sciences, especially those addressing global challenges, because these sciences must serve and be relevant to communities with an extraordinary diversity of cultures and values.

An Ecocultural Perspective on Eating-Related Routines Among Low-Income Families With Preschool-Aged Children

Eating-related routines, such as regular mealtimes, can protect against obesity. Little is known about eating-related routines among preschoolers or the factors that shape those routines. Ecocultural Theory and qualitative interviews with 30 caregivers of preschoolers in Colorado were used to describe eating-related routines at home and parents' perspectives on the factors that shape routines. Qualitative content analysis was used to analyze and interpret data. Consistent with clinical recommendations, parents' goals included dinner meals where adults and preschoolers eat the same food, in the same place, at the same time. However, parents' employment schedules and challenges in managing preschoolers' behavior prevented parents from consistently enacting recommended routines. Educating parents alone may not be sufficient to ensure optimal eating-related routines among preschoolers, and the household context needs to be considered. Families organized routines according to cultural values and available resources.

Global Health Research, Anthropology and Realist Enquiry

In this article, I set out to capture the dynamics of two streams within the field of global health research: realist research and medical anthropology. I critically discuss the development of methodology and practice in realist health research in low- and middle-income countries against the background of anthropological practice in global health to make claims on why realist enquiry has taken a high flight. I argue that in order to provide a contribution to today’s complex global issues, we need to adopt a pragmatic stance and move past disciplinary silos: both methodologies have the potential to be well-suited to an analysis of deep layers of context and of key social mechanisms.