Self-Care at the Margins: Meals and Meters in Migrants’ Diabetes Tactics

Isabella's lion: circular care, kinship, and healing in Brazilian Candomblé

This paper centers on Isabella, a Candomblé follower who struggled with severe rheumatoid arthritis from an early age, arguing that care and self-care practices in Candomblé are intertwined to such extent that they challenge the dichotomy of caring and being cared for. In contrast to a linear model of care that positions care-giver and care--receiver at opposite ends of care relationships, the concept of 'circular care' describes forms of care that are directed at others and simultaneously at oneself. Exploring the religious kinship in a Candomblé house - with Candomblé deities (orixás) and between humans - this paper shows how circular care blurs the distinction between self and other. The emic concept of 'the double mirror' illustrates the -'constitutive alterity' of humans and orixás who relate to each other through kinship building and collective care practices. Since circular care frames one's care for the orixás and the religious family as healing self-care, failing to provide the correct care may in turn be experienced as detrimental self-neglect. The concept of circular care thus enables a deeper understanding of complex dynamics of care and self-care in the contexts of chronic illness, religion, kinship, and beyond.

Managing disruption at a distance: Unequal experiences of people living with long-term conditions during the COVID-19 pandemic

The COVID-19 pandemic and 'lockdown' restrictions have affected people's health and wellbeing globally. Those who are clinically vulnerable to COVID-19 mortality due to living with long term conditions (LTCs) are at greater risk of negative impacts on their health and wellbeing, and of disruption in management of their LTCs. This study explores how people with LTCs managed their health and wellbeing under social distancing restrictions and self-isolation during the first wave of the COVID-19 pandemic, and examines why some people were more able to manage than others. Interviews were conducted between May and July 2020 with people (n = 44) living in North East England, who had one or more LTCs and were recruited via a social prescribing intervention. Data were analysed using a social constructivist thematic analysis. We present our analysis of the possibilities afforded to people to manage the impacts of lockdown on their health and wellbeing. We find that while some people deployed a range of capitals and/or etched out 'tactics' to make life 'habitable', others experienced 'zones of impossibility' requiring that they rely on contingent events or formal support. Our analysis highlights inequalities amongst people with LTCs, particularly regarding access to and deployment of important resources for health and wellbeing under COVID-19 social distancing restrictions, including outdoor space or greenspace, exercise and social connection. The study is novel in showing the mechanisms for coping with a significant period of disruption in the life-course whilst highlighting that although resilience was common in people with LTCs, this was sometimes at detrimental costs to themselves.

Goals of cure: Perspectives on the concept of cure in type 2 diabetes

RATIONALE, AIMS AND OBJECTIVES: Type 2 diabetes (T2D) is an archetypical chronic condition of significant prevalence. Yet the concept of cure in the context of T2D reveals an interplay between the medical imagination and clinical realities that can shift the course of a patient's care. There are two domains in which cure is sociologically constructed: the professional domain occupied by clinicians treating people with T2D, and the lay domain occupied by T2D patients. Lay epistemologies of cure tend to be focused on modifying the experience of having T2D, while professional epistemologies tend to focus on modifying the disease through medical treatment. The objective of this study is to explore the role of the concept of cure in the context of type 2 diabetes, a model for chronic disease.

METHODS

Through surveys and interviews of T2D patients, providers and researchers at an urban academic medical centre, I explore the perspectives and attitudes each group have towards the concept of cure in T2D. Semi-structured interviews of T2D professionals and patient surveys consisting of free response questions and Likert scale items were thematically analysed for perspectives on cure in T2D.

RESULTS

Sixteen T2D patients met inclusion criteria and consented to the survey and ten T2D professionals were interviewed. Cure is conceived of heterogeneously both within and between epistemologies. Patients carry hopes of cure predicated on eliminating the unpleasant experiences of T2D and its treatments, while T2D professionals tend to avoid invoking the concept of cure, at least to patients, on grounds of clinical uncertainty. However, the concept of cure is a significant motivator of treatment in both lay and professional epistemologies.

CONCLUSION

Different viewpoints on cure in T2D present an opportunity for shared meaning and decision making between patients and their providers that can frame the best possible outcome for patient care.

"I Do Not Have to Hurt My Body Anymore": Reproductive Chronicity and Sterilization as Ambivalent Care in Rural North India

Drawing on 18 months of ethnographic fieldwork in rural Rajasthan, India, I examine women's narratives of chronic reproductive suffering and the practices they employed to relieve it. Cumulative effects of adverse and ordinary reproductive events and exhaustion from caregiving were often seen as reproductive suffering, while sterilization emerged as an act of care toward women's ever-weakening bodies. Sterilization has been an integral part of the often coercive, incentive- and target-driven population control program in India. Rural women, however, described sterilization not as a form of violence but as an act of care, despite its ambivalence. In the context of reproductive chronicity-a persistent reproductive suffering recurring alongside reproductive events, available care options, relations within which these options are located, and structural conditions that shape women's lives-care and suffering are intimately and ambiguously intertwined.

"It Is a Full-time Job to Be Ill": Patient Work Involved in Attending Formal Diabetes Care Among Socially Vulnerable Danish Type 2 Diabetes Patients

Previous research has shown social inequality in type 2 diabetes prevalence and that socially vulnerable type 2 diabetes patients benefit less than average from health services. Based on ethnographic fieldwork carried out between February 2017 and March 2018 in a Danish specialized outpatient clinic, this article focuses on patient work among socially vulnerable type 2 diabetes patients. Through attending to the border zone between formal health care and self-care, we show that patients do a lot of work requiring skills, resources, and initiative, to access and benefit from formal care. This work is complex and implicit in the organization of care. Patients' social situations, especially their employment situation, complicate getting patient work done. Attending to patient work and implicit tasks in care organization may help us to see how social inequality in type 2 diabetes outcomes develops, and may be combated.

Flourishing: migration and health in social context

Health and the capacity to flourish are deeply intertwined. For members of vulnerable migrant groups, systemic inequalities and structural forms of marginalisation and exclusion create health risks, impede access to needed care and interfere with the ability to achieve one's full potential. Migrants often have limited access to healthcare, and they frequently are portrayed as less deserving than others of the resources needed to lead a healthy and flourishing life. Under these circumstances, clinicians, healthcare institutions and global health organisations have a moral and ethical obligation to consider the role they can-and do-play in either advancing or impeding migrants' health and their capacity to flourish. Drawing on case studies from three world regions, we propose concrete steps clinicians and health institutions can take in order to better serve migrant patients. These include recommendations that can help improve understanding of the complex circumstances of migrants' lives, strengthen collaboration between care providers and non-medical partners and transform the social, economic and structural circumstances that impede flourishing and harm health. Developing new strategies to promote the flourishing of precarious migrants can strengthen our collective ability to re-envision and redesign health systems and structures to value the health, dignity and bodily integrity of all patients-especially the most vulnerable-and to promote flourishing for all.

Multiplicidade, heterogeneidade e coordenação: a produção do cuidado em alimentação e nutrição a partir das práticas de apoio matricial

Resumo: Este estudo etnográfico buscou compreender o processo de produção do cuidado em alimentação e nutrição no âmbito da atenção primária à saúde, com base nas práticas de apoio matricial. O trabalho de campo foi realizado em duas unidades de saúde da família e seus respectivos territórios, junto à equipe do Núcleo Ampliado de Saúde da Família e Atenção Básica. Os dados foram analisados em interlocução com Deleuze e Guattari, Túlio Batista Franco e pesquisadores vinculados à Teoria Ator-Rede como Annemarie Mol e John Law. A investigação identificou que a produção do cuidado em alimentação e nutrição emerge de articulações entre múltiplos atores em redes dinâmicas e interligadas. As práticas de cuidado estão fortemente ligadas aos modos de inserção da alimentação no cotidiano de profissionais e usuários, expondo paradoxos nas relações de apoio mútuo e ampliação do acesso a alimentos nos territórios. Compondo a heterogeneidade material na mediação das interações, a comida destacava-se pela potência em provocar conexões. A comensalidade mobilizava subjetividades pelo uso de modos emocionais e sensoriais de conhecer, aprender e cuidar. Vivenciando tensões inerentes às relações entre micropolítica e macropolítica, as apoiadoras matriciais, em conjunto com os demais atores, coordenavam as redes para a produção do cuidado em alimentação e nutrição em um processo aberto, dinâmico, provisório, profuso e compartilhado. Tal compreensão pode contribuir para posicionamentos mais ativos e conscientes, que avançam no sentido da corresponsabilidade na luta pela implantação e execução de políticas públicas que oportunizem a garantia da Segurança Alimentar e Nutricional à população.

The tinkering m-patient: Co-constructing knowledge on how to live with type 1 diabetes through Facebook searching and sharing and offline tinkering with self-care

Danish adults with type 1 diabetes value peer-to-peer interaction through the social media platform Facebook as a way to quickly exchange knowledge on essential everyday self-care for chronic illness. In this praxiographic study, following informants into online and offline social dimensions, I explore how they use Facebook to exchange self-care knowledge based on practical experiments and negotiations between bodies, technologies and daily lives. When in doubt about how to self-care on a daily basis, Danish adults with type 1 diabetes look to Facebook for inspiration and peer support. A synergistic process of online searching and sharing and offline tinkering with self-care generates person-centred knowledge about how to live with illness that is situated to individual needs and unique daily lives. Facebook can be viewed as an emergent space for biosociality through which knowledge about how to self-care become co-constructed by peers based on their pragmatic experiences of self-care on a daily and ongoing basis.

"Como Si Nada": Enduring Violence and Diabetes among Rural Women in Southern Mexico

Rural women in Southern Mexico link their diabetes to distressful life experiences rooted in ordinary violence. While much has been written on the use that diabetes sufferers make of their morbid condition as an idiom of distress, I investigate the personal and social effects that such an idiom has on women. As I illustrate, diabetes reflects an ambivalence that helps women to speak about the unspeakable and, at the same time, reinforces their ideas of culpability, namely that they are to blame for both the gendered violence that they endure and the diabetes from which they suffer.

Embedded Narratives: Metabolic Disorders and Pentecostal Conversion in Samoa

Drawing from interviews and participant observation, this article explores the intersection of diagnosis of metabolic disorders and religious conversion among Pentecostal Christians in Samoa by analyzing what I call embedded narratives--conversion narratives embedded in illness narratives. Drawing from ethnographic data, I examine how using conversion narrative conventions enabled those living with metabolic disorders to narrate behavior change in a culturally and socially valorized way. By embedding their narratives, I suggest those living with metabolic disorders shifted the object of care from a disease process toward the creation of a religious life and in turn transformed the risks associated with metabolic disorders, including diet, exercise, and pharmaceutical use into moral risks associated with everyday religious life. In these cases, Pentecostal conversion created possible scripts for changing health practices, managing stress, and shifting resource use in the name of religious commitment, providing insights into how self-care can be an expression of religious practice.

Normalizing diabetes in Delhi: a qualitative study of health and health care

The Type 2 diabetes epidemic in India poses challenges to the health system. Yet little is known about how urban Indians view treatment and self-care. Such views are important within the pluralistic healthcare landscape of India, bringing together allopathic and non-allopathic (or traditional) paradigms and practices. We used in-depth qualitative interviews to examine how people living with diabetes in India selectively engage with allopathic and non-allopathic Indian care paradigms. We propose a 'discourse marketplace' model that demonstrates competing ways in which people frame diabetes care-seeking in India's medical pluralism, which includes allopathic and traditional systems of care. Four major domains emerged from grounded theory analysis: (1) normalization of diabetes in social interactions; (2) stigma; (3) stress; and (4) decision-making with regard to diabetes treatment. We found that participants selectively engaged with aspects of allopathic and non-allopathic Indian illness paradigms to build personalized illness meanings and care plans that served psychological, physical, and social needs. Participants constructed illness narratives that emphasized the social-communal experience of diabetes and, as a result, reported less stigma and stress due to diabetes. These data suggest that the pro-social construction of diabetes in India is both helpful and harmful for patients - it provides psychological comfort, but also lessens the impetus for prevention and self-care. Clarifying the social constructions of diabetes and chronic disease in India and other medically pluralistic contexts is a crucial first step to designing locally situated treatment schemes.

The body mechanical: Building a caring community, crafting a functioning body

When Hansen's disease became treatable in Taiwan in the mid-20th century, a group of Hansen's disease patients lost their sick role despite still having lingering symptoms that continued to evolve. While sociologists have explored in-depth situations in which the social role of the sick is ambiguous, few studies have investigated body experiences under liminality that requires sick people to find a new sick role. Living with lingering symptoms in a post-Hansen's disease world, the Hansen's disease patients I have studied face the conundrum of having to find an alternative sick role. Ethnographic fieldwork demonstrates how patients develop a specific set of body techniques that shape and are shaped by their membership in a patient community. Exploring the reinforcing projects of re-embodiment and sociality around Hansen's disease, I argue that patients are able both to legitimate each other's feelings of sickness and to use those feelings to manage their illness and, as such, to collectively acquire an alternative sick role. Adding to existing discussions of active patients, this article identifies the body mechanical as a way of practicing active patienthood organized around fixing, trials, mending and functionality.

Type 2 diabetes patients' and providers' differing perspectives on medication nonadherence: a qualitative meta-synthesis

BACKGROUND

Poor adherence to medication regimens increases adverse outcomes for patients with Type 2 diabetes. Improving medication adherence is a growing priority for clinicians and health care systems. We examine the differences between patient and provider understandings of barriers to medication adherence for Type 2 diabetes patients.

METHODS

We searched systematically for empirical qualitative studies on the topic of barriers to medication adherence among Type 2 diabetes patients published between 2002-2013; 86 empirical qualitative studies qualified for inclusion. Following qualitative meta-synthesis methods, we coded and analyzed thematically the findings from studies, integrating and comparing findings across studies to yield a synthetic interpretation and new insights from this body of research.

RESULTS

We identify 7 categories of barriers: (1) emotional experiences as positive and negative motivators to adherence, (2) intentional non-compliance, (3) patient-provider relationship and communication, (4) information and knowledge, (5) medication administration, (6) social and cultural beliefs, and (7) financial issues. Patients and providers express different understandings of what patients require to improve adherence. Health beliefs, life context and lay understandings all inform patients' accounts. They describe barriers in terms of difficulties adapting medication regimens to their lifestyles and daily routines. In contrast, providers' understandings of patients poor medication adherence behaviors focus on patients' presumed needs for more information about the physiological and biomedical aspect of diabetes.

CONCLUSIONS

This study highlights key discrepancies between patients' and providers' understandings of barriers to medication adherence. These misunderstandings span the many cultural and care contexts represented by 86 qualitative studies. Counseling and interventions aimed at improving medication adherence among Type 2 diabetes might become more effective through better integration of the patient's perspective and values concerning adherence difficulties and solutions.

Eating and Feeding at the Margins of the State: Barriers to Health Care for Undocumented Migrant Women and the "Clinical" Aspects of Food Assistance

In this article, I examine the various meanings of Mexican and Central American migrant women's utilization of private food assistance programs. I present findings from 20 months of ethnographic fieldwork conducted between 2008 and 2011 with migrant women, public health workers, and staff and volunteers of food assistance programs in Santa Barbara County, California. I discuss the barriers undocumented women face in accessing formal health care and the social and moral obligations that underpin these women's role in feeding others. I also document the ways in which private food assistance programs are orienting toward a focus on health in service delivery, and how women depend on provisions from these programs to support feeding practices at home. I argue that these findings are significant for current engagement by critical medical anthropologists in studying framings of "the clinic" and cultural beliefs about "deservingness."