Norms, Repertoires, & Intersections: Towards an integrated theory of culture for health research and practice

Public health scholars and practitioners have increasingly distanced themselves from the term "culture," which has been used to essentialize and blame marginalized "others." However, leading health theories inevitably entail the study of culture; omitting the term may sever vital connections to useful social theory. Instead, we propose the Intersectional Theory of Cultural Repertoires in Health (RiH), integrating social norms and intersectionality with repertoire theory, which has been highly influential in cultural sociology. We outline an approach to investigating relationships between cultural resources and health behaviors and illustrate the theory's application with two qualitative case studies. The cases demonstrate how RiH theory can elucidate the roles of cultural resources in influencing health outcomes, such as gender-equitable behavior in Nigeria and coping strategies in Haiti. Building on conventional normative explanations of health, we theorize how schemas, narratives, boundaries, and other cultural resources shape behavior and demonstrate how norms constrain the use of repertoires. We detail how this theory can deepen our understanding of health phenomena and identify future research priorities.

Correlates of Suicide Ideation and Resilience Among Native- and Foreign-Born Adolescents in the United States

PURPOSE

Nearly 20% of U.S. adolescents have considered suicide. Yet, gaps remain in understanding correlates of resilience and suicide risk, especially among populations born outside the United States who may face unique migration- and acculturation-related stressors. This study adds to the literature by exploring correlates of suicide ideation among a diverse population.

METHODS

This study analyzes quantitative data (N = 357) from the Study of Adolescent Lives after Migration to America, in Detroit and Harrisonburg. More than 40% of the sample was born outside the United States, with the majority born in the Middle East and North Africa. Path analysis was used to model dual outcomes of resilience and suicide ideation using measures of hope, school belonging, stressful life events, and being born outside the United States.

RESULTS

Suicide ideation and resilience were negatively correlated (ß = -.236[.069]; p < .001). Adolescents with greater hope (ß = .367; p < .001) and school belonging (ß = .407; p < .001) reported higher resilience, while lower levels of school belonging correlated with higher levels of suicide ideation (ß = -.248; p = .009). More stressful life events were associated with suicide ideation (ß = .243; p < .001), while fewer were correlated with resilience (ß = -.106; p = .003). Being born outside the United States was associated with suicide ideation (ß = .186; P-.015), with this finding driven by those from the Middle East and North Africa region, who faced significantly increased risk of suicide ideation (ß = .169; p = .036).

CONCLUSIONS

Findings suggest that adolescents born in the Middle East and North Africa region may represent a vulnerable group needing targeted and culturally responsive interventions to destigmatize mental health and psychosocial well-being, boost existing sources of resilience, and encourage help-seeking behaviors.

Who Stays at Home? The Politics of Social Distancing in Brazil, Mexico, and the United States during the COVID-19 Pandemic

CONTEXT

Reductions in population mobility can mitigate COVID-19 virus transmission and disease-related mortality. But do social distancing policies actually change population behavior and, if so, what factors condition policy effects?

METHODS

We leverage subnational variation in the stringency and timing of state-issued social distancing policies to test their effects on mobility across 109 states in Brazil, Mexico, and the United States. We also explore how conventional predictors of compliance, including political trust, socioeconomic resources, health risks, and partisanship, modify these policy effects.

FINDINGS

In Brazil and the United States, stay-at-home orders and workplace closures reduced mobility, especially early in the pandemic. In Mexico, where federal intervention created greater policy uniformity, workplace closures produced the most consistent mobility reductions. Conventional explanations of compliance perform well in the United States but not in Brazil or Mexico, apart from those emphasizing socioeconomic resources.

CONCLUSIONS

In addition to new directions for research on the politics of compliance, the article offers insights for policy makers on which measures are likely to elicit compliance. Our finding that workplace closure effectiveness increases with socioeconomic development suggests that cash transfers, stimulus packages, and other policies that mitigate the financial burdens of the pandemic may help reduce population mobility.

Risk and Refuge: Adolescent Boys' Experiences of Violence in "Post-Conflict" Colombia

Increasingly, researchers and practitioners are examining connections between public and private cycles of violence. In complex emergency settings, these cycles of violence often intersect with conflicting norms and values as societies work toward sustainable peace. Gender norms, particularly norms of masculinity, are not often highlighted in transdisciplinary violence studies. Furthermore, few studies on either subject capture the perspectives and experiences of adolescent boys. This study seeks to explore adolescent boys' (13-17 years) experiences with violence at home and in the community in "post-conflict" Colombia. Thematic qualitative analysis of 20 interview transcripts from 14 Colombian boys in Cundinamarca (n = 5) and Córdoba (n = 9) revealed themes of conflict avoidance, hegemonic masculinity, and opportunities for change in the form of positive coping habits. Further research into social and emotional coping behaviors and linkages to perpetuating violence between adolescence and adulthood is needed.

Supporting mental health and psychosocial wellbeing through social and emotional learning: A participatory study of conflict-affected youth resettled to the U.S

BACKGROUND

A growing literature has drawn attention to the central role that schools play in supporting the adjustment of resettled refugee youth and promoting their mental health and psychosocial wellbeing. In particular, the recent proliferation of school-based social and emotional learning (SEL) initiatives presents an opportunity to strengthen supports for resettled adolescents. This participatory research study aims to understand how high school students resettled from countries in the Middle East and North Africa region are experiencing the challenges and opportunities of acculturation and the ways in which they believe schools can better support them in this process.

METHODS

We analyzed primary data collected during focus group discussions as part of the SALaMA study. During these discussions, we used participatory ranking methodology to elicit adolescents' suggestions on how high schools can better support students both academically and psychosocially after resettlement. Fourteen focus group discussions were held with male (n = 38) and female (n = 31) adolescents aged 14-20 years, who were selected purposively across six public high schools in Harrisonburg, Virginia, Austin, Texas, and Detroit, Michigan. Participants offered suggestions and then ranked them in order of importance using consensus ranking.

RESULTS

Thematic analysis of the PRM results across sites produced a wealth of suggestions centered around three broad themes, namely: skills related to navigating social and academic challenges, culturally responsive teaching, and socially and culturally equitable learning environments.

CONCLUSIONS

Findings reported illustrate limitations of the conventional, universal SEL model and shed light on how schools can adapt transformative SEL strategies to serve their students better, especially newcomers from conflict-affected countries.

The role of culturally responsive social and emotional learning in supporting refugee inclusion and belonging: A thematic analysis of service provider perspectives

Young refugees resettled to the U.S. from the Middle East and North Africa (MENA) region face significant acculturative stressors, including language barriers, unfamiliar norms and practices, new institutional environments, and discrimination. While schools may ease newcomer adjustment and inclusion, they also risk exacerbating acculturative stress and social exclusion. This study seeks to understand the opportunities and challenges that schoolwide social and emotional learning (SEL) efforts may present for supporting refugee incorporation, belonging, and wellbeing. We completed semi-structured interviews with a purposive sample of 40 educators and other service providers in Austin, Texas, Harrisonburg, Virginia, and Detroit Metropolitan Area, Michigan as part of the SALaMA project. We conducted a thematic analysis with transcripts from these interviews guided by the framework of culturally responsive pedagogy. The findings revealed that students and providers struggled with acculturative stressors and structural barriers to meaningful engagement. Schoolwide SEL also provided several mechanisms through which schools could facilitate newcomer adjustment and belonging, which included promoting adult SEL competencies that center equity and inclusion, cultivating more meaningfully inclusive school climates, and engaging families through school liaisons from the newcomer community. We discuss the implications of these findings for systemwide efforts to deliver culturally responsive SEL, emphasize the importance of distinguishing between cultural and structural sources of inequality, and consider how these lessons extend across sectors and disciplinary traditions.

Pandemic Policymaking in Presidential Federations: Explaining Subnational Responses to Covid-19 in Brazil, Mexico, and the United States

Why do COVID-19 social distancing policies vary so widely across states in federal countries? This mixed-methods study of Brazil, Mexico, and the United States finds that state-level variation in the stringency of social distancing policies is driven not by the epidemiological, demographic, or socioeconomic factors commonly emphasized in previous research, but largely by political factors. Introducing a novel framework for explaining pandemic policymaking, the study shows the central importance of political parties, presidential power, and governors’ coalitions in determining state-level policy stringency. In the United States and Mexico, statistical and qualitative evidence indicates that interstate collaboration among governors, combined with top-down pressures from national party elites and presidents, led to greater policy alignment among coordinated states. In Brazil, in contrast, where there is little evidence of either policy coordination or alignment, state-level policies resulted instead from intrastate factors and diffusion. Together, these findings highlight how a multilevel framework attuned to varied combinations of intra-unit, cross-unit, and cross-level causal factors strengthens our understanding of pandemic policymaking.

Psychosocial Well-Being, Mental Health, and Available Supports in an Arab Enclave: Exploring Outcomes for Foreign-Born and U.S.-Born Adolescents

Introduction: Few studies have assessed the impact of displacement, resettlement, and discrimination on well-being outcomes for adolescent refugees resettled within the U.S. Conducted in three charter schools in the intergenerational Arab enclave of the Detroit Metropolitan Area, this mixed-methods study assessed the mental health and psychosocial support for both U.S.- and foreign-born adolescents from the Middle East and North Africa region. Methods: A quantitative survey was used to collect data on 176 students. Key outcomes included hope, prosocial behaviors, resilience, depressive, anxiety, externalizing symptoms, stressful life events, perceived social support, and sense of school belonging. Differences in outcomes between U.S.- and foreign-born students were compared using T-tests. Regression analysis explored whether outcomes were gendered and correlated with years in the U.S. for foreign-born students. Qualitative data collection included key informant interviews with school staff and community service providers, student focus group discussions, and caregiver interviews. Interview transcripts were analyzed using thematic analysis and the constant comparative method. Results: No statistically significant differences between the foreign-born and U.S.-born groups were observed. However, analysis revealed that resilience decreased for male students with time spent in the U.S. Qualitative themes illuminated these results; shared cultural heritage allowed newcomer students to access relevant language and psychosocial support, while inter- and intra-group peer relationships strengthened students' dual language skills and identity formation. However, shifting gender expectations and role hierarchies for newcomer students revealed boys' increased stressors in the family domain and girls' better accessed support in the school context. Conclusion: The existence of an immigrant paradox in this enclave setting was not supported. Instead, findings highlight the reciprocal value of peer-based mentorships and friendships between U.S.- and foreign-born students with similar cultural backgrounds, the importance of social and emotional curricula and cultural competency training within schools, and the gendered effects of acculturation.

Ecologies of care: mental health and psychosocial support for war-affected youth in the U.S

BACKGROUND

Youth resettling to the U.S. from conflict-affected countries in the Middle East and North Africa (MENA) face countless challenges. As they cope with their experiences of armed conflict and forced migration, these girls and boys must also adjust to the language and social norms of their new society, often encountering prejudice and discrimination along the way. Previous studies indicate that schools can play a central role in facilitating this adjustment while also promoting mental health and psychosocial wellbeing. This qualitative study aims to understand the lived experiences of MENA newcomers resettled in Austin, Texas and Harrisonburg, Virginia and to assess how schools, families, and communities support their mental and psychosocial wellbeing.

METHODS

We held six focus group discussions across the two cities with a total of 30 youths (13-23 years) from Iraq, Syria, and Sudan. We also conducted semi-structured interviews with 30 caregivers and 27 key informants, including teachers, administrators, service providers, and personnel from community-based organizations.

RESULTS

Guided by Bioecological Theory, our thematic analysis identifies several means by which various actors work together to support resettled adolescents. We highlight promising efforts that seek to enhance these supports, including sheltered instruction, school-parent collaboration, peer support programming, social and emotional learning initiatives, and integrated mental health centers.

CONCLUSION

While this study underscores the resilience of newcomers and the value of local support systems, it also reflects the importance of investment in schools, mental health systems, and resettlement programs that can enable newcomers to achieve their full potential.

School-based programs for Supporting the mental health and psychosocial wellbeing of adolescent forced migrants in high-income countries: A scoping review

As communities around the world continue to receive record-setting numbers of newcomers fleeing armed conflict, schools play a central role in supporting these families through the challenges of adjustment. Policymakers and educators in several high-income countries have begun to invest in efforts to support these young forced migrants not only academically, but also socially and emotionally. This study reviews the published and grey literature on 20 school-based programs aimed at improving the mental health and psychosocial wellbeing of adolescent forced migrants in high-income countries from 2000 to 2019. This review seeks to inform a more comprehensive and detailed understanding of the types of program options available to schools, while also identifying gaps in the current literature related to factors influencing program implementation. We find several common approaches and challenges to supporting adolescent forced migrants, as well as their families, communities, schools, and service providers. The reviewed programs faced recurring challenges related to intercultural exchange, gaining access to communities, promoting care-seeking, school capacity limitations, and sustainability. The lessons learned from these programs indicate that several steps can be taken to mitigate these challenges, including adapting services to individuals and their contexts, taking a multi-layered approach that addresses multiple levels of young people's social ecologies, and building trusting, collaborative partnerships with schools, communities, and students.

Assessing large-scale violence against children surveys in selected Southeast Asian countries: A scoping review

BACKGROUND

Violence against children (VAC) is a widespread, global issue with far-reaching social and economic consequences. In recent years, VAC has received substantial international attention, resulting in government initiatives to reduce VAC, in part, by strengthening data collection and information systems.

OBJECTIVE

This scoping review was undertaken to map survey methodologies for VAC measurement in Indonesia and other Southeast Asian countries and to identify key considerations for developing both methodologically sound and culturally appropriate VAC surveys in Indonesia and similar contexts.

METHODS

The authors conducted manual and automated searches in English and Bahasa Indonesia through PubMed, global databases, and websites, and consulted with partners from the government of Indonesia and the child protection field to identify surveys conducted from 2006 to 2016 in Indonesia and Southeast Asia. The search identified 275 records, of which 11 met all inclusion criteria.

RESULTS

The 11 surveys utilized a wide range of methodologies and employed inconsistent definitions, different age ranges for respondents, and different combinations of self-administered and face-to-face modes. A majority of the studies utilized household-based sampling, did not include a qualitative component, and used a tablet for data collection.

CONCLUSION

In developing VAC surveys, researchers should consider which groups of children are excluded from the sampling frame; how qualitative data can be used to strengthen the validity of survey results; how to maximize privacy in face-to-face interviews; and whether self-administered modes are feasible and acceptable. Researchers should also ensure that the survey and research protocol undergo rigorous ethical review.

Examining intersections between violence against women and violence against children: perspectives of adolescents and adults in displaced Colombian communities

BACKGROUND

Research examining the interrelated drivers of household violence against women and violence against children is nascent, particularly in humanitarian settings. Gaps remain in understanding how relocation, displacement and ongoing insecurity affect families and may exacerbate household violence.

METHODS

Employing purposive sampling, we used photo elicitation methods to facilitate semi-structured, in-depth interviews with female and male adolescents and adults aged 13-75 (n = 73) in two districts in Colombia from May to August of 2017. Participants were displaced and/or residing in neighborhoods characterized by high levels of insecurity from armed groups.

RESULTS

Using inductive thematic analysis and situating the analysis within a feminist socioecological framework, we found several shared drivers of household violence. Intersections among drivers at all socioecological levels occurred among societal gender norms, substance use, attempts to regulate women's and children's behavior with violence, and daily stressors associated with numerous community problems. A central theme of relocation was of family compositions that were in continual flux and of family members confronted by economic insecurity and increased access to substances.

CONCLUSIONS

Findings suggest interventions that systemically consider families' struggles with relocation and violence with multifaceted attention to socioecological intersections.

Converging drivers of interpersonal violence: Findings from a qualitative study in post-hurricane Haiti

OBJECTIVE

Interpersonal violence affecting women and children is increasingly recognized as a public health priority in humanitarian emergencies. Yet, research and intervention efforts have been fragmented across gender-based violence and child protection sectors. Using data from the Transforming Households: Reducing Incidence of Violence in Emergencies (THRIVE) project, this study sought to qualitatively investigate the intersecting drivers of multiple forms of violence in Côteaux, Haiti, while obtaining insight on how these drivers may be influenced by a humanitarian emergency.

METHODS

This analysis used transcripts obtained using a photo elicitation approach over the course of three sessions per person. Thirty-six individuals participated in the study: eight adult females, ten adult males, eight adolescent females, ten adolescent males. Participants were given cameras to capture images related to family relationships, family safety, and changes to family dynamics due to Hurricane Matthew and its aftermath. In subsequent sessions, these photographs were used as prompts for qualitative interviews.

RESULTS

Multiple and converging drivers of interpersonal violence were identified including the accumulation of daily stressors, loss of power/control, learned behavior (intergenerational cycle of abuse), and inequitable gender norms, all of which were influenced by the humanitarian context caused by Hurricane Matthew.

CONCLUSIONS

Our findings suggest multiple and converging drivers of violence may be exacerbated in times of crises, requiring interdisciplinary responses. In order to comprehensively address the drivers of violence, practitioners and policy makers should consider the needs of individuals and their families holistically, integrating community-led, gender transformative efforts and positive parenting with basic needs provision.

Monitoring and reporting attacks on education in the Democratic Republic of the Congo and Somalia

The United Nations' Monitoring and Reporting Mechanism is charged with documenting six grave violations against children in a time of conflict, including attacks on schools. Many of these incidents, however, remain unreported across the globe. This study explores whether or not a local knowledge base of education and child protection actors in North and South Kivu Provinces, Democratic Republic of the Congo, and in Mogadishu, Somalia, could contribute to a more complete record of attacks on education in those areas. Hundreds of semi-structured interviews were conducted with key informants across the three settings, and in total 432 attacks on education were documented. Purposive samples of these reports were verified and a large majority was confirmed. Local non-governmental organisations and education institutions were most knowledgeable about these incidents, but most never reported them to a monitoring authority. The study concludes that attack surveillance and response were largely insufficient, and recommends investing in mechanisms that utilise local knowledge to address these shortcomings.

Ethical considerations for children's participation in data collection activities during humanitarian emergencies: A Delphi review

Background

Children’s right to participate in data collection during emergencies has been widely recognized by humanitarian actors. However, participation in such activities can expose children to risk. Tensions have been noted between the right to participate and other principles, such as the imperative to ‘do no harm.’ With little evidence to inform guidance on addressing this tension, our study sought to identify expert consensus on whether and how children participate in emergency-related data collection activities.

Methods

We employed a three-round Delphi technique with a purposive sample of 52 child protection specialists. Respondents answered two open-ended questions in round one. A thematic analysis of responses generated a set of unique statements addressing the study questions. In the second round, respondents rated each statement on a five-point scale. In the final round, respondents reviewed the group’s average ratings for each statement with the option to revise their own ratings. A statement was said to have reached clear consensus when at least 90% of respondents agreed or strongly agreed with the statement.

Results

A total of 124 statements and 14 themes emerged from the thematic analysis, with 46.0% of statements reaching clear consensus in the third round. Respondents strongly supported children’s right to participate in data collection in humanitarian settings, while also recognizing that protecting children from harm may “over-ride” the participation principle in some contexts. Respondents identified capacity and contextual considerations as important factors influencing participation decisions, though they sometimes disagreed about how these factors should determine participation. Respondents also considered the role of individual child factors and the presence of caregivers in selecting child participants, and proposed best practice approaches for securing children’s safe and meaningful participation.

Conclusions

With almost half of statements reaching clear consensus, these findings reflect broad agreement within the sector about engaging children in data collection in emergencies. At the same time, points of ongoing debate around how to factor different risks into child participation decisions may indicate discordant practice. Further reflection is needed around how factors such as the phase of emergency, the existence of basic services, and cultural beliefs should influence whether and how children participate.

Electronic supplementary material

The online version of this article (doi:10.1186/s13031-017-0108-y) contains supplementary material, which is available to authorized users.

Transgender and Gender Nonconforming in Emergency Departments: A Qualitative Report of Patient Experiences

Background: Individuals who have a transgender or gender nonconforming (TGGNC) experience belong to a marginalized segment of the U.S. population, and healthcare can be difficult for them to navigate. Although emergency departments (EDs) traditionally serve as healthcare "safety nets" for vulnerable populations, quantitative studies outside the United States have found that TGGNC-experienced persons tend to avoid EDs and/or have negative experiences. This qualitative study primarily describes the ED experiences of people with a TGGNC history; furthermore, the study explores reasons why this population avoids U.S. EDs and their recommendations for improvements to ED care. Methods: This qualitative study used data about TGGNC-historied persons' experiences in U.S. EDs from retrospective, anonymous, written surveys (paper or web based). National data collection took place from June 2012 through December 2014. Participant responses (n=240) were examined using thematic analysis. Results: Using a framework that recognized positive and negative responses, the themes of Self-Efficacy and Power Inequity surfaced. These themes exposed the tension between patients with TGGNC experiences and clinicians who were perceived to lack training in this area, resulting in negative patient experiences. When practitioners had specific training about this population, participants reported positive care experiences. Conclusions: This study indicates that many TGGNC-historied persons who use U.S. EDs have negative experiences, largely due to lack of provider sensitivity toward and training about this patient population. Data from this investigation suggest that training of U.S. ED providers and institutional support would help improve care for this marginalized group.

Using the Three Delays Model to Examine Civil Registration Barriers in Indonesia

The Three Delays Model has proven a useful framework for examining barriers to seeking obstetric care and preventing maternal and child mortality. This article demonstrates the applicability of the Three Delays Model to the case of civil registration in rural Indonesia and examines ways that efforts to strengthen civil registration services can draw on lessons from maternal and child health programming. Twenty focus group discussions were conducted using a participatory ranking exercise in four Indonesian districts. Focus groups were stratified into four groups: (1) government officials involved in civil registration, (2) civil society organization members that assist communities in civil registration, and (3) female and (4) male community members. Transcripts were analyzed using constant comparative method and thematic analysis, revealing barriers that communities commonly faced in accessing civil registration services. In examining the categories and themes related to these barriers, the research team found a significant overlap with the factors and phases of the Three Delays Model. Participants were delayed from seeking registration services by a range of sociocultural factors and by the perceived inaccessibility and poor quality of services. Once they decided to seek care, long distances to services and poor transportation options delayed their access to registration offices. Finally, a series of bottlenecks in service provision created extended delays once applicants reached registration offices. Ownership of civil registration documents in Indonesia remains exceptionally low, with just over half of children and youth possessing a birth certificate. To strengthen civil registration and health systems more generally, it is important to understand the factors that enable and constrain civil registration, how these factors relate to one another, and how they change over a child’s life.