The Inherent Violence of Anti-Black Racism and its Effects on HIV Care for Black Sexually Minoritized Men

The goal of this study was to examine the effects of racial discrimination, depression, and Black LGBTQ community support on HIV care outcomes among a sample of Black sexually minoritized men living with HIV. We conducted a cross-sectional survey with 107 Black sexually minoritized men living with HIV in Chicago. A path model was used to test associations between racial discrimination, Black LGBTQ community support, depressive symptoms, and missed antiretroviral medication doses and HIV care appointments. Results of the path model showed that men who had experienced more racism had more depressive symptoms and subsequently, missed more doses of HIV antiretroviral medication and had missed more HIV care appointments. Greater Black LGBTQ community support was associated with fewer missed HIV care appointments in the past year. This research shows that anti-Black racism may be a pervasive and harmful determinant of HIV inequities and a critical driver of racial disparities in ART adherence and HIV care engagement experienced by Black SMM. Black LGBTQ community support may buffer against the effects of racial discrimination on HIV care outcomes by providing safe, inclusive, supportive spaces for Black SMM.

Profiles of childhood adversities in Inuit from Nunavik: description and associations with indicators of socioeconomic characteristics, support, and community involvement

OBJECTIVES

Distress and associated health problems reported by Nunavik Inuit emanate from heterogeneous roots, including adverse childhood experiences. This study aims to (1) identify distinct childhood adversity profiles and (2) examine associations between these profiles and sex, socioeconomic characteristics, social support, and community involvement among Nunavimmiut.

METHODS

In a sample of 1109 adult Nunavimmiut, sex, socioeconomic characteristics, support, community involvement, residential school attendance, and 10 forms of adverse childhood experiences (ACEs) were documented using questionnaires. Latent class analyses and weighted comparisons were performed for three subgroups: 18-49 years; 50 years and above with experience of residential school; and 50 years and above without experience of residential school. The analysis design, the manuscript drafts, and the key findings were discussed and co-interpreted with the collaboration of community representatives, taking into consideration Inuit culture and needs.

RESULTS

A total of 77.6% of Nunavimmiut reported having experienced at least one form of childhood adversity. Three ACE profiles were identified among the 18-49-year-olds: low ACEs (43.0%), household stressors (30.7%), and multiple ACEs (26.3%). Two profiles characterized ACEs experienced among the 50-year-olds and over with and without history of residential schooling: low ACEs (80.1% and 77.2%, respectively) and multiple ACEs (19.9% and 22.8%, respectively). Among the group of 18-49-year-olds, as compared to the low ACE profile, the profile with household stressors included proportionally more women (odds ratio [OR] = 1.5) and was associated with lower involvement in volunteering and community activities (mean score reduced by 0.29 standard deviation [SD]) and lower family cohesion (SD = - 0.11), while the multiple ACE profile was related to a lower rate of employment (OR = 0.62), lower family cohesion (SD = - 0.28), and lower satisfaction with ability to practice traditional activities (SD = - 0.26).

CONCLUSION

Childhood adversities among Nunavimmiut do not occur in isolation and experiencing multiple forms of childhood adversities predicts lower socioeconomic status, support, and community involvement in adulthood. Implications for the planning of health and community services in Nunavik are discussed.

Exploring the varied manifestations of structural violence in the lives of children on the autism spectrum and their families: a qualitative longitudinal study in Kurdistan, Iran

BACKGROUND

There are many dimensions regarding autism that are closely connected to social structures, policies, and power dynamics, silently impacting the well-being of individuals within the autism spectrum. This research aims to explore these overlooked aspects using a theoretical framework called "structural violence."

METHODS

The study was conducted in Kurdistan, Iran, and a qualitative longitudinal approach was chosen. A purposive sampling method was employed to select the participants, with 11 parents taking part. The study data comprised 29 interviews using a topic guide conducted over a span of 2 years. Thematic analysis and a matrix-based approach were utilized for data analysis. To enhance the scientific rigor of this research, four criteria, including Guba and Lincoln's principles, were implemented to ensure methodological accuracy.

RESULTS

The research findings highlight four primary forms through which structural violence impacts children on the autism spectrum and their families: access to healthcare, geographic disparities, awareness and stigma, and poverty and financial burden. Additionally, the study identified 11 subthemes related to structural violence in the context of autism and families.

CONCLUSIONS

We illustrated how structural forces create barriers to accessing adequate healthcare services, exacerbate discrimination based on ethnicity and geography, perpetuate stigma, and contribute to poverty and the inability to meet basic needs. These factors not only worsen health issues but also deepen existing disparities in healthcare access and outcomes for children on the autism spectrum and families. We emphasize the urgent need for systemic changes to address these issues. It is essential to promote public awareness, provide better access to health and support services, and address economic and political factors that contribute to these inequalities.

Reorienting the focus from an individual to a community-level lens to improve the pathways through care for early psychosis in the United States

The implementation of coordinated specialty care in the U.S. over the past decade has led to the improvements of clinical and functional outcomes among individuals in the early stages of psychosis. While there have been advancements in the delivery of early intervention services for psychosis, it has almost exclusively focused on short-term change at the individual level. In light of these advancements, research has identified gaps in access to care and delivery of services that are driven by different levels of determinants and have the biggest impact on historically excluded groups (e.g., ethnoracial minoritized communities). Interventions or efforts that place an emphasis on community level (structural or sociocultural) factors and how they may influence pathways to care and through care, specifically for those who have been historically excluded, have largely been missing from the design, dissemination and implementation of early psychosis services. The present paper uses a structural violence framework to review current evidence related to pathways to care for early psychosis and the physical/built environment and conditions (e.g., urbanicity, residential instability) and formal and informal community resources. Suggestions on future directions are also provided, that focus on enriching communities and creating sustainable change that spans from pathways leading to care to 'recovery.' In all, this lays the groundwork for a proposed paradigm shift in research and practice that encompasses the need for an emphasis on structural competency and community-driven approaches.

The Dreamwork of the Symptom: Reading Structural Racism and Family History in a Drug Addiction

A key tenet of critical health research is that individual symptoms must be considered in light of the social and political contexts that shape or, in some cases, produce them. Precisely how oppressive social forces give rise to individual symptoms, however, remains challenging to theorize. This article contributes to debates over the interpretation of symptoms through a close reading of the case of Leon, an African American man struggling with an addiction to crack cocaine. Leon presented a complex illness narrative in which his addiction was clearly a product of structural racism, but also the result of dynamics within his family. Drawing on critical reevaluations of Freud's concept of the dreamwork, I call attention to the surface elements of Leon's narrative-what I term the surface of the symptom-and to the formal mechanisms by which latent contents (such as the social, the political, and the personal) are transformed into the manifest form of his symptom. This formal mode of reading offers a productive way of approaching questions of demystification and interpretation, one that holds in tension the register of social causation with the singularities of individuals and their symptoms.

Black Mothers in Racially Segregated Neighborhoods Embodying Structural Violence: PTSD and Depressive Symptoms on the South Side of Chicago

This study employs multi-level and mixed-methods approaches to examine how structural violence affects the health of low-income, single Black mothers. We use multilevel regression models to examine how feeling "trapped" in racially segregated neighborhoods with high levels of violence on the South Side of Chicago affects mothers' (N = 69) reports of posttraumatic stress disorder and depressive symptoms. The relationship between feeling "trapped" and variations in expression of mRNA for the glucocorticoid receptor gene NR3C1 using microarray assays was also examined. The regression models revealed that feeling "trapped" significantly predicted increased mental distress in the form of PTSD, depressive symptoms, and glucocorticoid receptor gene regulation. The mothers' voices revealed a nuanced understanding about how a lack of financial resources to move out of the neighborhood creates feelings of being "trapped" in dangerous situations.

"The pandemic only gave visibility to what is invisible": a qualitative analysis of structural violence during COVID-19 and impacts on gender-based violence in Brazil

BACKGROUND

The COVID-19 pandemic produced alarming rates of disease and mortality globally, yet few nations were as severely impacted as Brazil. The pandemic also exposed and exacerbated persistent forms of structural violence across Brazil, which complicated gender-based violence (GBV) prevention and response efforts. While structural violence is not new, the systemic pressure and uncertainty introduced by COVID-19 intensified the detrimental impact of structural violence on the lives of Brazilians impacted by GBV. This work qualitatively investigated how the COVID-19 pandemic amplified structural violence and GBV in Brazil.

METHODS

We analyzed key informant interviews (KII) conducted with 12 service providers working in sectors related GBV prevention and response in Roraima, Boa Vista, and Rio de Janeiro. Interviews were audio-recorded, transcribed, and translated from Portuguese or Spanish into English, before applying deductive and inductive coding approaches through a collaborative data reduction process. The theoretical lens of structural violence outlined by Farmer and Rylko-Bauer guided the thematic development.

RESULTS

Analyses identified three themes. First, structural violence manifests as policies of inaction and erasure, which reduce the opportunity for upward social mobility among GBV survivors including Black women, trans persons, and people who live in the favelas. Policies of inaction and erasure fail to acknowledge/adequately respond to the significant health and safety needs of these communities. Second, structural violence is a fundamental cause of violence against women and children. Finally, service providers described community driven responses that address the dire survival needs (i.e., food insecurity) imposed by COVID-19, within a context of structural violence. These community driven responses were innovative, agile, and based on dire needs expressed to, and observed by, the service providers interviewed.

CONCLUSION

This analysis highlights how the COVID-19 pandemic exacerbated existing forms of structural violence prevalent throughout Brazil. Findings stress the urgency with which the Brazilian government and international organization must act to support community driven programs that strive to address the most basic human needs.

"When you leave your country, this is what you're in for": experiences of structural, legal, and gender-based violence among asylum-seeking women at the Mexico-U.S. border

BACKGROUND

Recent U.S. immigration policy has increasingly focused on asylum deterrence and has been used extensively to rapidly deport and deter asylum-seekers, leaving thousands of would-be asylum-seekers waiting indefinitely in Mexican border cities, a large and growing proportion of whom are pregnant and parenting women. In the border city of Tijuana, Mexico, these women are spending unprecedented durations waiting under unsafe humanitarian conditions to seek safety in the U.S, with rising concerns regarding increases in gender-based violence (GBV) among this population during the COVID-19 pandemic. Given existing gaps in evidence, we aimed to describe the lived experiences of GBV in the context of asylum deterrence policies among pregnant and parenting asylum-seeking women at the Mexico-U.S. border.

METHODS

Within the community-based Maternal and Infant Health for Refugee & Asylum-Seeking Women (MIHRA) study, we conducted semi-structured qualitative interviews with 30 asylum-seeking women in Tijuana, Mexico between June and December 2022. Eligible women had been pregnant or postpartum since March 2020, were 18-49 years old, and migrated for the purposes of seeking asylum in the U.S. Drawing on conceptualizations of structural and legal violence, we conducted a thematic analysis of participants' experiences of GBV in the context of asylum deterrence policies and COVID-19.

RESULTS

Pregnant and parenting asylum-seeking women routinely faced multiple forms of GBV perpetuated by asylum deterrence policies at all stages of migration (pre-migration, in transit, and in Tijuana). Indefinite wait times to cross the border and inadequate/unsafe shelter exacerbated further vulnerability to GBV. Repeated exposure to GBV contributed to poor mental health among women who reported feelings of fear, isolation, despair, shame, and anxiety. The lack of supports and legal recourse related to GBV in Tijuana highlighted the impact of asylum deterrence policies on this ongoing humanitarian crisis.

CONCLUSION

Asylum deterrence policies undermine the health and safety of pregnant and parenting asylum-seeking women at the Mexico-U.S. border. There is an urgent need to end U.S. asylum deterrence policies and to provide respectful, appropriate, and adequately resourced humanitarian supports to pregnant and parenting asylum-seeking women in border cities, to reduce women's risk of GBV and trauma.

'Our hands are bound': Pathways to community health labour in Kenya

An ideal model of Community Health Worker (CHW) selection has existed since long before Alma Ata catalysed the community health approach, dating to late colonial times. In this model, a willing, trusted, relatively well-educated and secure member of the community with proven aptitude is openly elected by their leadership, peers or relevant committee. Their participation is entirely voluntary and that voluntarism is symbolic of their community's participation as a whole. While this imagery is long-embedded in CHW storytelling, such practice is rare. While elements of this 'model pathway' exist, a myriad of structural and agential factors shape who becomes a CHW, how and why. Through life history interviews over twelve months 2022-2023 with 68 CHWs in Isiolo, northern Kenya (known as CHVs), we explore predominant pathways to community health labour as told through stories. We articulate five such pathways: model, handpicked, shadow, outsider and, most importantly, dispossession. Through telling five CHVs' stories, we present each 'ideal type' but also explore how each pathway is not singular, rather overlapping in complex, context-specific ways. These pathways confound Western-centric, Western-promoted notions of voluntarism and indeed community health, which cannot explain why such labour endures. We conclude that our findings provide a timely commentary on how voluntary labour within health continues to tax structural poverty and frustrated life chances in lieu of concrete and expansive investments in human resources for health by governments and health agencies both North and South. In understanding voluntary labour as a form of structural violence, we can better elucidate the historical dependency on this work in impoverished regions and how the undervaluing of such work persists over time.

Global inequities in access to COVID-19 health products and technologies: A political economy analysis

This paper presents a political economy analysis of global inequities in access to COVID-19 vaccines, treatments, and diagnostic tests. We adapt a conceptual model used for analysing the political economy of global extraction and health to examine the politico-economic factors affecting access to COVID-19 health products and technologies in four interconnected layers: the social, political, and historical context; politics, institutions, and policies; pathways to ill-health; and health consequences. Our analysis finds that battles over access to COVID-19 products occur in a profoundly unequal playing field, and that efforts to improve access that do not shift the fundamental power imbalances are bound to fail. Inequitable access has both direct effects on health (preventable illness and death) and indirect effects through exacerbation of poverty and inequality. We highlight how the case of COVID-19 products reflects broader patterns of structural violence, in which the political economy is structured to improve and lengthen the lives of those in the Global North while neglecting and shortening the lives of those in the Global South. We conclude that achieving equitable access to pandemic response products requires shifting longstanding power imbalances and the institutions and processes that entrench and enable them.

"When there is no money, that is when I vomit blood": the domino effect and the unfettered lethal exploitation of Black labor on Dominican sugar plantations

BACKGROUND

In this article, I utilize the concept of the Plantationocene as an analytical framework to generate a holistic and historical understanding of the present-day struggles of a mostly Haitian migrant workforce on sugar plantations in the Dominican Republic.

METHODS

Inspired by Paul Farmer's methodology, I combine political economy, history, and ethnography approaches to interpret the experiences of sugarcane cutters across historical and contemporary iterations of colonial, post-colonial, and neo-colonial practices over the course of five centuries.

RESULTS

My findings elucidate the enduring power of capitalism, implicating corporate and state elites, as the structural scaffolding for acts of racialized violence that condition the life-and-death circumstances of Black laborers on Caribbean plantations to this day. Although today's sugarcane cutters may suffer differently than their enslaved or wage labor ancestors on the plantation, I argue that an unfettered racialized pattern of lethal exploitation is sustained through the structural violence of neoliberalism that links present conditions with the colonial past.

CONCLUSIONS

Ultimately, this paper contributes understandings of the plantationocene's enduring effects in the global south by demonstrating how imperialist arrangements of capitalism are not a distant memory from the colonial past but instead are present yet hidden and obscured while relocated and reanimated overseas to countries like the Dominican Republic, where American capitalists still exploit Black bodies for profit and power.

Messaging inclusion with consequence: U.S. sanctuary cities and immigrant wellbeing

In the United States (U.S.), sanctuary cities have increasingly garnered public attention as places dedicated to increasing immigrant safety, inclusion, and health. These cities primarily rely on limiting local police cooperation with federal immigration enforcement to deter immigrant detention and deportation. However, sanctuary policies' inability to extend immigrants' legal rights and their reliance on police as ushers of sanctuary may complicate how these spaces attend to their stated goals. In this paper, we examine how organizational workers conceptualize sanctuary, safety, and immigrant health and wellbeing within sanctuary cities. We draw on interviews with organizational workers in two sanctuary cities: Boston, Massachusetts and Seattle, Washington collected between February and August 2018. Our findings reveal that immigrants continue to face structural barriers to housing, safe employment, education, and healthcare within sanctuary cities with consequences to wellbeing. Workers' definitions of safety draw on interconnected structural exclusion that prevent immigrants from accessing basic needs and fail to account for historically rooted forms of racism and nativism. Organizational workers identified tensions between messages of sanctuary and what local sanctuary policies offer in practice, providing insight into consequences of institutionalizing a grassroots social movement. As organizational workers negotiate these tensions, they must develop everyday sanctuary practices to extend immigrant inclusion, safety, health, and wellbeing.

Structural Violence and Stress Experiences of Young Pregnant Black People

INTRODUCTION

Approximately 10-20% of individuals suffer from mental health concerns during the prenatal period due to their vulnerability and emotional responses to stressful events. Mental health disorders are more likely to be disabling and persistent for people of color, and they are less likely to seek treatment due to stigma. Young pregnant Black people report experiencing stress due to isolation, feelings of conflict, lack of material and emotional resources, and support from significant others. Although many studies have reported the types of stressors experienced, personal resources, emotional stress responses on pregnancy, and mental health outcomes, there is limited data on young Black women's perceptions of these factors.

METHODS

This study utilizes the Health Disparities Research Framework to conceptualize drivers of stress related to maternal health outcomes for young Black women. We conducted a thematic analysis to identify stressors for young Black women.

RESULTS

Findings revealed the following overarching themes: Societal stress of being young, Black, and pregnant; Community level systems that perpetuate stress and structural violence; Interpersonal level stressors; Individual level effects of stress on mom and baby; and Coping with stress.

DISCUSSION

Acknowledging and naming structural violence and addressing structures that create and fuel stress for young pregnant Black people are important first steps to interrogating systems that allow for nuanced power dynamics and for recognizing the full humanity of young pregnant Black people.

Responding to Health Outcomes and Access to Health and Hospital Services in Rural, Regional and Remote New South Wales

Ethical perspectives on regional, rural, and remote healthcare often, understandably and importantly, focus on inequities in access to services. In this commentary, we take the opportunity to examine the implications of normalizing metrocentric views, values, knowledge, and orientations, evidenced by the recent (2022) New South Wales inquiry into health outcomes and access to hospital and health services in regional, rural and remote New South Wales, for contemporary rural governance and justice debates. To do this, we draw on the feminist inspired approach to rural health ethics involving analysis of power relationships developed by Simpson and McDonald and related ideas from critical health sociology. In presenting this analysis, we extend contemporary thought about spatial health inequities and structural violence.

Caribbeanist casualties: Interrogating the application of structural vulnerability to forensic anthropology

Biocultural approaches are instrumental to the evolution of forensic anthropology, and this practice must first reckon with its own violences before it can ethically address structural violence at large. We take up the issue of coerced migrations of Caribbean populations and forensic practice at the southern border of the United States, to problematize how forensic identification standards contribute to the casualties of ethnic erasures and potentially exacerbate structural vulnerability of Black Caribbean populations. We put forward that forensic anthropology is complicit in maintaining inequality in death and identification for Black Caribbean migrants through the absence of necessary reference data and methods of population-affinity estimation, and the adoption of fundamentally flawed linguistic constructions of Blackness. Pushing forensic anthropology to continue engaging with the colonial logics that have shaped its understanding and motivation for quantifying human biologies is key in efforts toward a progressive disciplinary future.

'The area I'm from is very rough': Drug users' views on the role of social and economic factors in their experiences of drug-related harm

Over the last thirty-five years, academic researchers in Ireland have consistently demonstrated the relationship between social deprivation and the most severe instances of drug-related harm. More recently, researchers have begun to include the voices of drug users with lived experiences of harm in these discussions. However, these studies have more often tended to focus on drug users' views on alternative drug policy options, rather than their views on the social and economic factors relevant to their experiences of drug-related harm. Therefore, the current study conducted 12 in-depth interviews with drug users experiencing harm in an Irish city, in order to elicit their views on the specific role they believe social and economic factors played in conditioning their later experiences of drug--related harm. The study participants highlight harms experienced in the education system, the family home, and the local community as more relevant to their later experiences of drug-related harm than their social deficits in education, a lack of resources in the local community or in their families. Many participants also discuss meaningful relationships as the last defence against these harms and argue that the loss of such relationships coincided with their most severe incidences of drug-related harm. The study concludes with a discussion of the conceptual framework of structural violence in terms of its potential for interpreting the participants' views and suggests several avenues for further research.

"Letting die" by design: Asylum seekers' lived experience of postcolonial necropolitics

Although the United States has been a nation of immigrants since its founding, the massive number of asylum seekers arriving at the US-Mexico Border is a relatively new phenomenon that requires attention and study. This paper describes the lived experience of three asylum seekers, demonstrating how physical and mental health are structured by US policies and politics. The in-depth accounts are informed by participant observation and policy analysis of humanitarian, non-governmental organizations advocating for asylum seekers. We focus on health and geographical trajectories using the triple trauma paradigm that includes trauma in the country of origin, trauma incurred during transit/flight, and the trauma of arrival and relocation/resettlement in the host country. We suggest that a form of necropower, understood as processes exacerbating the potentiality for death, is embedded in the structure of the US asylum apparatus.

The lived experience of stigma and parkinson's disease in Kenya: a public health challenge

BACKGROUND

As a disease characterised by non-motor and very visible motor symptoms, Parkinson's disease has been associated with multiple forms of stigma, while awareness about the disease globally remains low. The experience of stigma relating to Parkinson's disease from high-income nations is well-documented, while less is known about low- and middle-income countries (LMICs). Literature on stigma and disease from Africa and the Global South has described the added complexities people face resulting from structural violence, as well as perceptions about symptoms and disease associated with supernatural beliefs, which can have significant implications for access to healthcare and support. Stigma is a recognised barrier to health-seeking behaviour and a social determinant of population health.

METHODS

This study draws on qualitative data collected as part of a wider ethnographic study to explore the lived experience of Parkinson's disease in Kenya. Participants include 55 people diagnosed with Parkinson's and 23 caregivers. The paper draws on the Health Stigma and Discrimination Framework as a tool to understand stigma as a process.

RESULTS

Data from interviews identified the drivers and facilitators of stigma, including poor awareness of Parkinson's, lack of clinical capacity, supernatural beliefs, stereotypes, fear of contagion and blame. Participants reported their lived realities of stigma, and experiences of stigma practices, which had significant negative health and social outcomes, including social isolation and difficulty accessing treatment. Ultimately, stigma had a negative and corrosive effect on the health and wellbeing of patients.

CONCLUSION

This paper highlights the interplay of structural constraints and the negative consequences of stigma experienced by people living with Parkinson's in Kenya. The deep understanding of stigma made possible through this ethnographic research leads us to see stigma as a process, something that is embodied and enacted. Targeted and nuanced ways of tackling stigma are suggested, including educational and awareness campaigns, training, and the development of support groups. Importantly, the paper shows that awareness of, and advocacy for the recognition of, Parkinson's globally needs to improve. This recommendation is in line with the World Health Organization's Technical Brief on Parkinson disease, which responds to the growing public health challenge posed by Parkinson's.

Structural violence and the uncertainty of viral undetectability for African, Caribbean and Black people living with HIV in Canada: an institutional ethnography

Biomedical advances in healthcare and antiretroviral treatment or therapy (ART) have transformed HIV/AIDS from a death sentence to a manageable chronic disease. Studies demonstrate that people living with HIV who adhere to antiretroviral therapy can achieve viral suppression or undetectability, which is fundamental for optimizing health outcomes, decreasing HIV-related mortality and morbidity, and preventing HIV transmission. African, Caribbean, and Black (ACB) communities in Canada remain structurally disadvantaged and bear a disproportionate burden of HIV despite biomedical advancements in HIV treatment and prevention. This institutional ethnography orients to the concept of 'structural violence' to illuminate how inequities shape the daily experiences of ACB people living with HIV across the HIV care cascade. We conducted textual analysis and in-depth interviews with ACB people living with HIV (n = 20) and health professionals including healthcare providers, social workers, frontline workers, and health policy actors (n = 15). Study findings produce a cumulative understanding that biomedical HIV discourses and practices ignore structural violence embedded in Canada's social fabric, including legislation, policies and institutional practices that produce inequities and shape the social world of Black communities. Findings show that inequities in structural and social determinants of health such as food insecurity, financial and housing instability, homelessness, precarious immigration status, stigma, racial discrimination, anti-Black racism, criminalization of HIV non-disclosure, health systems barriers and privacy concerns intersect to constrain engagement and retention in HIV healthcare and ART adherence, contributing to the uncertainty of achieving and maintaining undetectability and violating their right to health. Biomedical discourses and practices, and inequities reduce Black people to a stigmatized, pathologized, and impoverished detectable viral underclass. Black people perceived as nonadherent to ART and maintain detectable viral loads are considered "bad" patients while privileged individuals who achieve undetectability are considered "good" patients. An effective response to ending HIV/AIDS requires implementing policies and institutional practices that address inequities in structural and social determinants of health among ACB people.

Beyond the report: Prospects and challenges in forensic anthropological investigations of structural vulnerability

Forensic anthropologists are increasingly interested in accounting for embodied marginalization in addition to the biological profile. A structural vulnerability framework, which assesses biomarkers of social marginalization in individuals within forensic casework, is worthwhile but its application must be informed by ethical, interdisciplinary perspectives that reject categorizing suffering within the pages of a case report. Drawing from anthropological perspectives, we explore prospects and challenges of evaluating embodied experience in forensic work. Particular attention is paid to how forensic practitioners and stakeholders utilize a structural vulnerability profile within and beyond the written report. We argue that any investigation of forensic vulnerability must: (1) integrate rich contextual data, (2) be evaluated for potential to perpetuate harm, and (3) serve the needs of a diverse array of stakeholders. We call for a community-oriented forensic practice, wherein anthropologists may act as advocates for policy change to disrupt power structures driving vulnerability trends in their region.

Structural violence within communities and its impact on the well-being of people with HIV (PWH)

Structural violence (SV) is the concept that there are often invisible and intangible structures in place, whether political, economic, legal, cultural, religious, or social, that can inhibit individuals from reaching their full potential. There is a need to better understand the influence of SV on the well-being of people with HIV (PWH) in the Deep South. To address this gap in the literature, we interpreted data using a Structural Violence framework. In this community-based participatory research, in-depth interviews (n = 40) were conducted with PWH who previously established HIV medical care. In our study, we found that SV can have a widespread impact in communities, negatively impacting access to key tangible and emotional resources. SV themes included community crime and instability, financial insecurity, and disparate access to numerous resources known to influence health. Structures exacerbating unequal access to resources appear engrained within communities and often went unrecognized by participants as disadvantageous to achieving optimal HIV health. Greater effort is necessary to elucidate the influence and role of violent structures on access to key resources for and by PWH. A clearer understanding of SV's influence on HIV health can inform changes addressing these structural barriers to HIV health.

Causative effects of cranial depression fractures: A case study of structural violence and social vulnerability within the Mississippi state asylum

Cranial depression fractures (CDFs) are often associated with violence in a forensic and bioarchaeological context. Interpretations of CDFs, using a structural vulnerability framework, allow for examination of possible socioeconomic and sociocultural factors that influence an individual's life history. Placement of CDFs in relation to traumatic brain injuries (TBIs) and their potential connections to structural violence become essential for analysis. This case study presented Burial 49 from the Mississippi State Lunatic Asylum (MSA). Burial 49 was an adult individual (probable male) who exhibited antemortem trauma to the left parietal bone with an associated CDF. The injury location had the potential to cause a variety of neurological and developmental issues, including difficulty understanding spoken/written language. This case study demonstrates how CDFs, structural violence, and social vulnerabilities might have contributed to an increased risk of MSA admittance and provide context for why this individual was marginalized.

From rhetorical "inclusion" toward decolonial futures: Building communities of resistance against structural violence

In this paper, we name and uplift the ways in which Miya community workers are building communities of resistance as ways to address the manifold colonial, structural (including state-sponsored), and epistemic violence in their lives. These active spaces of refusal and resistance constitute the grounds of our theorizing. Centering this theory in the flesh, we offer critical implications for decolonial liberatory praxis, specifically community-engaged praxis in solidarity with people's struggles. In doing so, we speak to questions such as: What are the range of ways in which Global South communities are coming together to tackle various forms of political, social, epistemic, and racial injustice? What are ways of doing, being, and knowing that are produced at the borders and liminal zones? What are the varied ways in which people understand and name solidarities, alliances, and relationalities in pursuit of justice? We engage with these questions from our radically rooted places in Miya people's struggles via storytelling that not only confronts the historical and ongoing oppression, but also upholds desire-Interweaving and honoring rage, grief, pain, creativity, love, and communality.

A community-led mobile health clinic to improve structural and social determinants of health among (im)migrant workers

BACKGROUND

Community-led interventions that address structural and social determinants of health are lacking among (im)migrant workers, especially seafood workers. This lack of medical attention is especially alarming given their high rate of injury and death.

METHODS

Community-based participatory research (CBPR), a relational model that values the participants as equal partners in research, dissemination, and implementation, guided the interviews and mobile clinic. Seafood workers were engaged throughout data collection, analysis, and interpretation and played a significant role in moving the findings from research into actionable change.

RESULTS

To address the lack of healthcare options for (im)migrants, and at the request of the seafood workers participating in the ongoing CBPR study, we successfully implemented and treated workers in our mobile clinic.

DISCUSSION

Many of these individuals had not been seen by a healthcare provider in years, highlighting the importance of community trust and rapport building when addressing interconnected health and safety issues.

CONCLUSIONS

Although CBPR and free (mobile) health clinics are in and of themselves not novel concepts, when applied to high-risk occupational settings with under-reached populations (e.g., (im)migrant workers), they have the ability to improve health and prevent injury. This intervention adds to the growing literature detailing the potential benefits of using CBPR, and meeting people where they are, especially with historically marginalized populations.

Structural violence and the need for compassionate use of methadone in Mexico

BACKGROUND

Epidemiological data from Mexico have documented an increase in heroin use in the last decade. However, there is no comprehensive care strategy for heroin users, especially those who have been accused of a crime. The objective of this study was to describe the heroin and methadone use of intravenous heroin users of both sexes who have been in jail, to offer evidence for the formulation of health policy.

METHODS

This study used an ethnographic approach, with open-ended interviews carried out from 2014 to the present. Heroin users of both sexes attending a private methadone clinic in Mexico City were invited to participate. The sample was non-probabilistic. All interviews were audiotaped and transcribed, and narratives were analyzed using thematic analysis.

RESULTS

Participants in this study were 33 users of heroin, two of them women, who had been in prison. They ranged in age from 33 to 62 years, had used heroin for a period of 13-30 years, and were from three states: Michoacan, Oaxaca, and Mexico City. Three principal categories of analysis were structured: 1. Pilgrimage for help (dynamics of the drama of suffering, pain, and time through health care spaces); 2) methadone use as self-care; and 3) accessibility to methadone treatment. The impossibility of access to methadone treatment is a condition which motivates users in their journey. The dynamics of methadone use are interpreted as a form of self-care and care to avoid substance use. Reducing the psychological, physical, and harmful effects of the substance allows them to perform daily activities. The inability to access treatment leads to a significant effect on users who experience structural violence.

CONCLUSION

Compassionate methadone treatment and holistic attention should be considered as a way to meet patients' needs and mitigate their suffering, based on public health policy that allows for human rights-based care.

Policy Implications of Structural Violence and Syndemic Dynamics: A Lens for Addressing Latinx Immigrant Diabetes Health Disparities

PURPOSE OF REVIEW

The purpose of this review is to explore using theoretical frameworks of structural violence and syndemics to understand Latinx health disparities with a focus on type 2 diabetes (T2D). We propose that combining these frameworks is a valuable approach for revealing complex root-cause dynamics and explaining the nuances of how and why health disparities exist. We discuss the importance of the relationship between T2D, fear, and stigma.

RECENT FINDINGS

Immigration policy creates structural conditions that invite unauthorized immigration while simultaneously excluding undocumented immigrants from access to healthcare resources. Structural exclusion then breeds fear of immigration status disclosure and deportation and, in the highly politicized immigration context that has emerged over the past two decades, also assigns social sigma to immigration status. Undocumented immigrants lack access to healthcare and health insurance; they cannot afford state-of-the-art drugs, they tend to be socially isolated and lack social capital to navigate systems; they are financially limited by poverty and lack of resources, emotionally taxed by the experience of discrimination, humiliation, and language-related challenges; and they have a toxic immigration stress load in the form of multidimensional fear. Potential areas for policy change are identified. Type 2 diabetes (T2D) follows racial, ethnic, and class fault lines that reflect unequal social and structural dynamics. Latinx immigrants are at disproportionate risk and explaining immigrant T2D social geography requires a holistic lens.

Demilitarizing Hospital Restraints: Recognizing the Stones in Our Glass Houses

As the debate within the United States about reforming its militarized police force continues, psychiatrists need to critically reflect on their profession's role in perpetuating structural violence. Research shows that the now well-documented disproportionate use of force against people of color in many communities is also mirrored in the hospital setting. The authors of this Open Forum provide a structurally informed perspective on the use of restraints in their practice, highlight the persistence of police weaponry in hospitals despite recommendations to abolish it, and call on regulatory authorities and clinicians to make changes that address these health inequities.

The invisibility of farmworkers: Implications and remedies

This article highlights the invisibility of farmworkers in Michigan, a state dependent on migrant labor for more than one hundred years. The study describes migrant housing camps using data from fieldwork, visits to housing camps, and the shadowing of outreach staff from service organizations. Although regulated, accommodations are minimal, substandard, and overcrowded, affecting the health and well-being of workers. The study describes what farmworkers do in their scant evening hours, the vulnerability of H-2A guest workers, the meticulousness accompanying outreach, and how farmworkers are visible to outreach staff. The study concludes by highlighting how farmworkers are just as invisible as are their housing camps, their contributions to the food movement, and their erasure from historic tales and promotional materials in local tourist towns, which stress the contributions of only some groups. The article underscores the value of outreach, the outstanding work performed by outreach staff, and avenues for increasing the visibility and advocacy on behalf of farmworkers.

Food Access, Food Insecurity, and Gun Violence: Examining a Complex Relationship

PURPOSE OF REVIEW

Food insecurity and gun violence are timely and relevant public health issues impacting many regions within the USA with a potential association. Terminology surrounding food access and food security can be confusing, which is important to understand when examining the relationship between these issues and gun violence.

RECENT FINDINGS

Food insecurity is an individual level risk factor that appears to correlate with an increased rate of exposure and future involvement in violence. Food deserts represent geographic regions with limited access to food but do not necessarily represent regions with high prevalence of food insecurity. Although both food insecurity and food deserts in urban regions have been linked with increased incidence of gun violence, a high prevalence of food insecurity was found to be more predictive. A high prevalence of food insecurity in urban regions likely serves as a marker for socioeconomic disadvantage and intentional disinvestment. These regions are predictably associated with a higher incidence of interpersonal gun violence. Food deserts in rural areas have not, to date, been shown to correlate with interpersonal gun violence. Urban food insecurity and gun violence are both likely the byproduct of structural violence. Despite the significant overlap and similar contributors, the application of the public health framework in addressing these two issues has historically been quite different.

"They're Not Closing This School, We Won't Let Them"

This autoethnography details the story of my personal experience in the field as a social work MSW and Ph.D. student, working as the facilitator of a human rights-based after-school and summer program at an urban high school set for permanent closure in a structurally oppressed community, and my journey to the realization that I was witnessing genocide in the form of structural violence. One purpose in writing this narrative is to provide a social and cultural context to the ubiquity of structurally violent policies, such as closing public schools. This story also testifies to the wealth of strengths that youth possess to resist even the most severe human rights abuses. I also write to show the inextricable political link between individuals and societal structures and systems and to challenge social workers to actively oppose structural violence and its genocidal effects. As I reflect on the genocidal conditions I witnessed, I will at the same time critically consider the profession of social work's role in responding to structural violence, as well as the great potential that our profession has to meaningfully address crises like these.

Hoots and harm reduction: a qualitative study identifying gaps in overdose prevention among women who smoke drugs

BACKGROUND

Smoking or inhaling illicit drugs can lead to a variety of negative health outcomes, including overdose. However, most overdose prevention interventions, such as supervised consumption services (SCS), prohibit inhalation. In addition, women are underrepresented at SCS and are disproportionately impacted by socio-structural violence. This study examines women's experiences smoking illicit drugs during an overdose epidemic, including their utilization of a women-only supervised inhalation site.

METHODS

Qualitative research methods included on-site ethnographic observation and semi-structured interviews with 32 participants purposively recruited from the women-only site. Data were coded and analyzed using NVivo 12 and thematic analysis was informed by gendered and socio-structural understandings of violence.

RESULTS

Participants had preferences for smoking drugs and these were shaped by their limited income, inability to inject, and perceptions of overdose risk. Participants expressed the need for services that attend to women's specific experiences of gendered, race-based, and structural violence faced within and outside mixed-gender social service settings. Results indicate a need for sanctioned spaces that recognize polysubstance use and drug smoking, accommodated by the women-only SCS. The smoking environment further fostered a sociability where participants could engage in perceived harm reduction through sharing drugs with other women/those in need and were able to respond in the event of an overdose.

CONCLUSIONS

Findings demonstrate the ways in which gendered social and structural environments shape women's daily experiences using drugs and the need for culturally appropriate interventions that recognize diverse modes of consumption while attending to overdose and violence. Women-only smoking spaces can provide temporary reprieve from some socio-structural harms and build collective capacity to practice harm reduction strategies, including overdose prevention. Women-specific SCS with attention to polysubstance use are needed as well as continued efforts to address the socio-structural harms experienced by women who smoke illicit drugs.

Fostering Well-being through Social Support: The Role of Evangelical Communities in the Lives of Dominican Women of Haitian Descent

Women of Haitian descent living in the Dominican Republic experience oppression due to their gender, ethnicity, and economic status. They also exhibit high rates of participation in evangelical Christian communities, a paradoxical finding given the restricted roles women have traditionally played in these settings. The goals of this study were to explore the perceived benefits of participation in evangelical communities and the setting characteristics that lead to these benefits. The research team interviewed 19 current and former church participants aged 18-59. Thematic analysis revealed three perceived benefits of congregational life. Participants viewed their participation as: (a) an opportunity for personal growth and development; (b) protective against negative social influences; and (c) providing social support in the face of life challenges. In addition, dependable, expected, and reciprocal relational support was a key characteristic of evangelical communities. Findings extend the current understanding of how religious communities enhance well-being for marginalized women through social support networks. Findings also explore the dialectical nature of settings as both empowering and disempowering. Implications for future interventions are discussed.

Towards health equity for people experiencing chronic pain and social marginalization

Objective

For people who experience social inequities and structural violence, pain and related care are inexorably linked to experiences of injustice and stigma. The purpose of this study was to examine in greater depth the experiences of pain and discrimination and stigma across diverse marginalized communities in order to recommend equity-oriented healthcare approaches.

Methods

This community-based qualitative study reports on four focus groups that included 36 people living with pain. All participants identified with one of three groups known to experience high levels of inequities and structural violence including an Indigenous group, a LGBTQ2S group, and two newcomer and refugee groups.

Results

Pain was entangled with and shaped by: social locations and identities, experiences of violence, trauma and related mental health issues, experiences of discrimination, stigma and dismissal, experiences of inadequate and ineffective health care, and the impacts of these intersecting experiences.

Conclusions

Equity-oriented responses to chronic pain would recognize pain not only as a biomedical issue but as a social justice issue. The EQUIP Framework is an approach to integrating trauma- and violence-informed care; culturally-safe care; and harm reduction in health care that may hold promise for being tailored to people experiencing pain and social marginalization.

Sexual risk behaviors and the legacy of colonial violence among Northern plains American Indian youth: A mixed methods exploratory study

INTRODUCTION

In this article, we honor the tribal remembering of two Northern Plains tribes to illustrate how the legacy of colonial violence frames the way in which substance use and mental health affect sexual risk behaviors among American Indian youth on the reservation today.

METHODS

We used a multi-phase, mixed quantitative and qualitative methods design within a community based participatory research framework to illustrate how the legacy of colonial violence frames epidemiological links between substance use, mental health, and sexual risk behavior among American Indian youth. We conducted semistructured interviews with 29 individuals and administered questionnaires to 298 American Indian youth living in a reservation environment.

RESULTS

Our findings explicate how a legacy of colonial violence underlies epidemiological links between mental health and substance use with sexual risk behavior among youth. Salient facets of colonial violence included systematically altered living arrangements, the boarding school era, eroded traditional practices, and the entry of extractive industries onto native lands.

DISCUSSION

The colonial violence enacted against the ancestors of Northern Plains tribal peoples materializes in the health of those living on the reservation today. Community interventions, which seek to address the role of substance use and mental health in sexual risk behavior, could benefit from delineating tribal perceptions regarding the legacy of colonial violence on public health outcomes through the use of a CBPR framework.

Health for all? A qualitative study of NGO support to migrants affected by structural violence in northern France

France hosts approximately 368,000 'persons of concern' (e.g. refugees, stateless, people in refugee-like situations, asylum-seekers). Northern France has become a focal area, due to its proximity to the Dover entry-point to the UK and larger numbers of migrants. This study used a structural violence lens to explore the provision of health services to migrants in Calais and La Linière in northern France, to contribute to discourse on the effects of structural violence on non-state service providers and migrants in precarious conditions and inform service provision policies. Our qualitative study design used semi-structured key-informant interviews, conducted in summer 2017 with 20 non-governmental service-providers, 13 who had worked in Calais and 7 in La Linière migrant camp. We analysed interviews thematically, using inductive coding. Themes from analysis were: (i) power dynamics between NGOs and the state; (ii) resource allocation and barriers to accessing services; and (iii) effects of structural violence on social determinants of health. NGO service provision varied due to tense power dynamics between state and NGOs, shifting state requirements, and expanding roles. Interviewees described ongoing uncertainties, and inherent disempowerment associated with humanitarian aid, as negatively affecting migrant health and wellbeing, increasing illness risks, and providing unequal life chances. Structural realities including violence appeared to negatively affect migrant social determinants of health, reducing healthcare access, social inclusion, and sense of empowerment. The role of NGOs in providing migrant health services in northern France was complex and contested. Structural violence negatively affected migrant wellbeing through restricted services, intentional chaos, and related disempowerment. The violence exerted on migrants appeared to diminish their life chances while being an ineffective deterrent, indicating better approaches are needed.

Beyond awareness: Towards a critically conscious health promotion for rheumatic fever in Aotearoa, New Zealand

Since 2014, the Rheumatic Fever Prevention Programme has targeted communities in Aotearoa, New Zealand affected by high rates of rheumatic fever (RF): namely, Māori and Pacific families. Initiated with the aim of reducing ethnic health disparities, the Health Promotion Agency attempted to use culturally appropriate approaches by engaging in consultative processes with Māori and Pacific communities and health leaders in developing the intervention. However, these consultations largely focused on evaluating strategies for reaching "priority" audiences with the message to get sore throats checked and on changing health-seeking behaviours. There was little regard for what the structural roots of RF in Aotearoa might suggest about equitable interventions, nor for the potentially harmful effects of the messages and their presentation. The concept of structural violence can be a useful analytical tool to critically evaluate such interventions which attempt to address health disparities but do not meaningfully attend to equity. Drawing on three ethnographic studies with: 1) Northland Māori families (Anderson et al., 2015); 2) North Island Māori and Pacific families (Anderson et al., 2017); and 3) Māori and Pacific children at a South Auckland school (Spray, 2020), we show how recategorising RF disparities as expressions of violence reveals how, despite including cultural consultation, interventions may still inequitably distribute responsibility. In particular, by responsibilising communities affected with the highest rates of RF, the intervention creates collateral damage of stigma, internalised blame, emotional suffering and hypervigilance that reproduces structural violence. We suggest that attending to how families experience public health messaging in the context of their daily lives may guide a more critical and culturally safe health promotion that looks beyond awareness and behaviour and towards equity.

Sociocultural aspects of drug dependency during early pregnancy and considerations for screening: Case studies of social networks and structural violence

OBJECTIVE

To contribute in closing the current gap in literature that holistically examines sociocultural influences on perinatal drug dependency. This article draws from social network theory and structural violence to qualitatively consider the contextual components of addiction and substance use during pregnancy, which purposefully moves away from situating this issue from solely being within the contexts of pathologized disorders or products of social inequalities.

DESIGN

Face-to-face semi-structured interviews with drug-dependent pregnant women identified during a reproductive environmental health consultation.

SETTING

Interviews were conducted at a university hospital in southeastern Spain between October 2015 and June 2016.

PARTICIPANTS

10 pregnant women with confirmed perinatal substance use and/or drug dependency.

FINDINGS

The sociocultural perspective offers a useful lens by which providers can understand the reasons for initial substance use and progress of multi-drug dependency as way of individually tailoring intervention strategies for expecting mothers. This perspective draws from the frameworks of social network analysis (SNA) and structural violence to dialectically examine drug dependency in this unique patient population not to be solely an individual occurrence, but rather a combination of macro and micro-level factors at play.

KEY CONCLUSIONS

The sociocultural approach in examining maternal health allows for the holistic exploration of the already taboo and symbolically paradoxical phenomenon of drug dependency in pregnant women.

IMPLICATIONS FOR PRACTICE

The "Hoja Verde" and similar perinatal screening methods that comprehensively assess for the potential of environmental risks can be a key instrument in the practice of preventing developmental issues of children as early as pregnancy and into adolescence.

Zika, abortion and health emergencies: a review of contemporary debates

BACKGROUND

The Zika outbreak provides pertinent case study for considering the impact of health emergencies on abortion decision-making and/or for positioning abortion in global health security debates.

MAIN BODY

This paper provides a baseline of contemporary debates taking place in the intersection of two key health policy areas, and seeks to understand how health emergency preparedness frameworks and the broader global health security infrastructure is prepared to respond to future crises which implicate sexual and reproductive rights. Our paper suggests there are three key themes that emerge from the literature; 1) the lack of consideration of sexual and reproductive health (SRH) services in outbreak response 2) structural inequalities permeate the landscape of health emergencies, epitomised by Zika, and 3) the need for rights based approaches to health.

CONCLUSION

Global health security planning and response should specifically include programmatic activity for SRH provision during health emergencies.

The role of structural violence in family homelessness

OBJECTIVE

This study examines the impacts of structural violence on women and how this can influence their trajectory into and their sustainable exits from homelessness.

METHODS

The research is qualitative and community-based, including 15 interviews with mothers living in emergency shelters and a group interview with nine professionals. An advisory group was formed through partnership with community services to provide project oversight and guide and interpret the results. A member check group consisting of seven mothers with recent experiences of homelessness was engaged to further refine findings and implications. The research team used Critical Social Theory, in particular feminist theory, as an analysis framework in order to account for the implications of structural violence on mothers with diverse and complex histories.

RESULTS

The results highlight three structural-level factors: gendered pathways into homelessness, systems of support that create structural barriers, and disjointed services that exacerbate trauma.

CONCLUSION

The authors propose systems-level changes rooted in trauma-informed approaches to facilitate a sustainable exit from homelessness for mothers and their children.

A comparative ethnography of nutrition interventions: Structural violence and the industrialisation of agrifood systems in the Caribbean and the Pacific

Public health interventions that involve strategies to re-localise food fail in part because they pay insufficient attention to the global history of industrial food and agriculture. In this paper we use the method of comparative ethnography and the concept of structural violence to illustrate how historical and geographical patterns related to colonialism and industrialisation (e.g. agrarian change, power relations and trade dependencies) hinder efforts to address diet-related non-communicable diseases on two small islands. We find comparative ethnography provides a useful framework for cross-country analysis of public health programmes that can complement quantitative analysis. At the same time, the concept of structural violence enables us to make sense of qualitative material and link the failure of such programmes to wider historical and geographical processes. We use ethnographic research carried out from April to August 2013 and from June to July 2014 in Trinidad (with follow-up online interviews in 2018) and in Nauru from February to May 2010 and August 2010 to February 2011. Our island case studies share commonalities that point to similar experiences of colonialism and industrialisation and comparable health-related challenges faced in everyday life.

Interactions Between Direct and Structural Violence in Sexual Harassment Against Spanish and Unauthorized Migrant Women

This article analyzes the intersection of direct and indirect violence against Spanish women and unauthorized migrant women working in precarious jobs in Almeria (Spain). Specifically, it seeks to understand how unauthorized migrant women define violence, the relationship between sexual harassment and other types of direct violence (such as intimate partner violence), and structural, legal, and cultural violence. To do this, we apply a multilevel intersectional analysis focusing on 32 interviews with Spanish and unauthorized migrant women. Three levels of intersectionality are shown. In the first, the interviewees do not label verbal abuse as sexual harassment. They attribute the abuse to their work. In the second, sexual harassment seems to be tied to "respect" and not "love," which explains why sexual harassment has less devastating consequences for women than intimate partner violence. In the third, experiences of sexual harassment differ between Spanish women and unauthorized migrant women, and a combination of sexual harassment and xenophobic and racist behavior occasionally appeared.

Disruption as opportunity: Impacts of an organizational health equity intervention in primary care clinics

BACKGROUND

The health care sector has a significant role to play in fostering equity in the context of widening global social and health inequities. The purpose of this paper is to illustrate the process and impacts of implementing an organizational-level health equity intervention aimed at enhancing capacity to provide equity-oriented health care.

METHODS

The theoretically-informed and evidence-based intervention known as 'EQUIP' included educational components for staff, and the integration of three key dimensions of equity-oriented care: cultural safety, trauma- and violence-informed care, and tailoring to context. The intervention was implemented at four Canadian primary health care clinics committed to serving marginalized populations including people living in poverty, those facing homelessness, and people living with high levels of trauma, including Indigenous peoples, recent immigrants and refugees. A mixed methods design was used to examine the impacts of the intervention on the clinics' organizational processes and priorities, and on staff.

RESULTS

Engagement with the EQUIP intervention prompted increased awareness and confidence related to equity-oriented health care among staff. Importantly, the EQUIP intervention surfaced tensions that mirrored those in the wider community, including those related to racism, the impacts of violence and trauma, and substance use issues. Surfacing these tensions was disruptive but led to focused organizational strategies, for example: working to address structural and interpersonal racism; improving waiting room environments; and changing organizational policies and practices to support harm reduction. The impact of the intervention was enhanced by involving staff from all job categories, developing narratives about the socio-historical context of the communities and populations served, and feeding data back to the clinics about key health issues in the patient population (e.g., levels of depression, trauma symptoms, and chronic pain). However, in line with critiques of complex interventions, EQUIP may not have been maximally disruptive. Organizational characteristics (e.g., funding and leadership) and characteristics of intervention delivery (e.g., timeframe and who delivered the intervention components) shaped the process and impact.

CONCLUSIONS

This analysis suggests that organizations should anticipate and plan for various types of disruptions, while maximizing opportunities for ownership of the intervention by those within the organization. Our findings further suggest that equity-oriented interventions be paced for intense delivery over a relatively short time frame, be evaluated, particularly with data that can be made available on an ongoing basis, and explicitly include a harm reduction lens.

Exploring community capacity: Karen refugee women's mental health

PURPOSE

The purpose of this paper is to describe Karen refugee women's experience of resettlement and the factors which structured community capacity to support their mental health and well-being.

DESIGN/METHODOLOGY/APPROACH

A postcolonial and feminist standpoint was used to bring Karen women's voice to the knowledge production process. Data were collected through ethnographic field observation, in-depth semi-structured individual and focus group interviews with Karen women as well as healthcare and social service providers.

FINDINGS

Three interrelated themes emerged from the data: Karen women's construction of mental health as "stress and worry"; gender, language and health literacy intersected, shaping Karen women's access to health care and social resources; flexible partnerships between settlement agencies, primary care and public health promoted community capacity but were challenged by neoliberalism.

RESEARCH LIMITATIONS/IMPLICATIONS

Karen women and families are a diverse group with a unique historical context. Not all the findings are applicable across refugee women.

PRACTICAL IMPLICATIONS

This paper highlights the social determinants of mental health for Karen women and community responses for mitigating psychological distress during resettlement.

SOCIAL IMPLICATIONS

Public health policy requires a contextualized understanding of refugee women's mental health. Health promotion in resettlement must include culturally safe provision of health care to mitigate sources of psychological distress during resettlement.

ORIGINALITY/VALUE

This research brings a postcolonial and feminist analysis to community capacity as a public health strategy.

Life on the margins: the experiences of sexual violence and exploitation among Eritrean asylum-seeking women in Israel

BACKGROUND

Eritrean migrants in Israel, the majority of whom are seeking asylum, have limited access to institutional support. While the temporary group protection granted to Eritreans by Israel ensures that they are not deported, it does not confer permanent legal status, nor does it allow access to the formal work sector. This study qualitatively explores how political and economic marginalization increases the risk of sexual and other forms of violence as well as the exploitation of Eritrean women asylum seekers living in Israel.

METHODS

Twenty-five interviews with key informants, twelve individual interviews (six with men and six with women), and eight focus group discussions (four with men and four with women) were conducted among Eritreans of reproductive age in Tel Aviv, Israel. Qualitative data analysis was conducted using open, focused, and axial coding.

RESULTS

Participants reported that Israel's restrictive immigration policies laid the foundation for the political and economic marginalization of asylum seekers. This manifested in limited access to institutional support during and after arrival, and hindered access to formal employment and its associated protections. The Israeli government's decision to grant provisional status with a stipulation banning Eritreans from the formal work sector was perceived to create direct and indirect conditions for a heightened sense of structural vulnerability, particularly for women. Participants reported that this structural vulnerability increased the risk of sexual and domestic violence in addition to the risk for the exploitation of women asylum seekers.

CONCLUSIONS

Israel's immigration policies may contribute to women asylum seekers' vulnerability to sexual violence upon arrival in their host country. These policies shape the social realities of women asylum seekers, potentially increasing their risk of violence and exploitation during their time in Israel. This study provides an example of the effects of political and economic marginalization on violence against women, a concept that may apply to other settings globally.

Preventable perinatal deaths in indigenous Wixárika communities: an ethnographic study of pregnancy, childbirth and structural violence

BACKGROUND

Preventable maternal and infant mortality continues to be significantly higher in Latin American indigenous regions compared to non-indigenous, with inequalities of race, gender and poverty exacerbated by deficiencies in service provision. Standard programmes aimed at improving perinatal health have had a limited impact on mortality rates in these populations, and state and national statistical data and evaluations of services are of little relevance to the environments that most indigenous ethnicities inhabit. This study sought a novel perspective on causes and solutions by considering how structural, cultural and relational factors intersect to make indigenous women and babies more vulnerable to morbidity and mortality.

METHODS

We explored how structural inequalities and interpersonal relationships impact decision-making about care seeking during pregnancy and childbirth in Wixarika communities in Northwestern Mexico. Sixty-two women were interviewed while pregnant and followed-up after the birth of their child. Observational data was collected over 18 months, producing more than five hundred pages of field notes.

RESULTS

Of the 62 women interviewed, 33 gave birth at home without skilled attendance, including 5 who delivered completely alone. Five babies died during labour or shortly thereafter, we present here 3 of these events as case studies. We identified that the structure of service provision, in which providers have several contiguous days off, combined with a poor patient-provider dynamic and the sometimes non-consensual imposition of biomedical practices acted as deterrents to institutional delivery. Data also suggested that men have important roles to play supporting their partners during labour and birth.

CONCLUSIONS

Stillbirths and neonatal deaths occurring in a context of unnecessary lone and unassisted deliveries are structurally generated forms of violence: preventable morbidities or mortalities that are the result of systematic inequalities and health system weaknesses. These results counter the common assumption that the choices of indigenous women to avoid institutional delivery are irrational, cultural or due to a lack of education. Rather, our data indicate that institutional arrangements and interpersonal interactions in the health system contribute to preventable deaths. Addressing these issues requires important, but achievable, changes in service provision and resource allocation in addition to long term, culturally-appropriate strategies.

"Violence" in medicine: necessary and unnecessary, intentional and unintentional

We are more used to thinking of medicine in relation to the ways that it alleviates the effects of violence. Yet an important thread in the academic literature acknowledges that medicine can also be responsible for perpetuating violence, albeit unintentionally, against the very individuals it intends to help. In this essay, I discuss definitions of violence, emphasizing the importance of understanding the term not only as a physical perpetration but as an act of power of one person over another. I next explore the paradox of a healing profession that is permeated with violence sometimes necessary, often unintentional, and almost always unrecognized. Identifying the construct of "physician arrogance" as contributory to violence, I go on to identify different manifestations of violence in a medical context, including violence to the body; structural violence; metaphoric violence; and the practice of speaking to or about patients (and others in the healthcare system in ways that minimize or disrespect their full humanity. I further suggest possible explanations for the origins of these kinds of violence in physicians, including the fear of suffering and death in relation to vicarious trauma and the consequent concept of "killing suffering"; as well as why patients might be willing to accept such violence directed toward them. I conclude with brief recommendations for attending to root causes of violence, both within societal and institutional structures, and within ourselves, offering the model of the wounded healer.

Police crackdowns, structural violence and impact on the well-being of street cannabis users in a Nigerian city

BACKGROUND

There is abundant literature on the impact of law enforcement on cannabis markets, but scant literature on the effects of law enforcement on cannabis users. This study undertook a qualitative exploration of police crackdowns as a form of structural violence and examined their impact on the well-being of street cannabis users in a Nigerian city.

METHODS

The study was qualitative and descriptive. It was carried out in Uyo, southern Nigeria. Ninety-seven (97) frequent cannabis users (78 males and 19 females) took part. They were aged between 21 and 34 years and recruited from 11 cannabis hot-points in the city. Data were collected through in-depth, individual interviews, conducted over six-months. Data analysis was thematic and data-driven, involving identifying themes, assigning codes, revising codes and verification by independent qualitative methodology experts.

RESULTS

Police crackdowns are commonly experienced by street cannabis users. These do not reduce cannabis use, but displace cannabis markets. Crackdowns are associated with police brutality, confiscation of funds, drugs and belongings, stigma and discrimination, arrest and incarceration, which impacts negatively on the health, livelihoods and well-being of cannabis users. Cannabis users try to escape arrest by running from police, disposing of cannabis, disguising themselves and, when caught, bribing officers to secure release.

CONCLUSION

Crackdowns constitute a form of structural violence in the everyday life of cannabis users, and have negative effects on their health and social and economic well-being. Cannabis use should be decriminalized de facto and arrested users directed to treatment and skills training programmes. Treatment and social services for users should be expanded and legal aid interventions should be mounted to support users in addressing discriminatory practices and human rights violations.

Health in the Tenderloin: A resident-guided study of substance use, treatment, and housing

Substance use researchers recognize that environments - our homes, streets, communities, and neighborhoods - set the stage for substance use and treatment experiences by framing interactions, health options, and decision-making. The role of environment is particularly salient in places deemed disadvantaged or risky, such as parts of the Tenderloin neighborhood of San Francisco. Since risk is historically, socially, and structurally situated, an individual's social position in a neighborhood shapes how risk environments are experienced. The purpose of this study was to explore how the environment shapes substance use and treatment experiences, described from the perspective of Tenderloin residents. I conducted docent method interviews with formerly homeless women living in supportive housing in San Francisco (N = 20). The docent method is a three-stage, participant-led, audiotaped, and photographed walking interview. As they guided me through target "sites of interest" (homes, streets, treatment programs, and safe spaces), participants discussed their experiences with substance use and treatment in the environment. First, they described that the risks of a broader drug market are concentrated in the Tenderloin, exposing residents to elevated and disproportionate risk. Second, for structural, economic, social, and physical reasons, participants described a sense of geographic or neighborhood stratification. Third, multiple levels of policing and surveillance were persistent, even in participants' homes. Fourth, despite all the challenges, participants found security and support in the Tenderloin, and considered it their home. In the discussion, I offer that the Tenderloin environment provided residents many advantages, but forms of structural and everyday violence largely defined their experiences in the neighborhood.

Austerity and the embodiment of neoliberalism as ill-health: Towards a theory of biological sub-citizenship

This article charts the diverse pathways through which austerity and other policy shifts associated with neoliberalism have come to be embodied globally in ill-health. It combines a review of research on these processes of embodiment with the development of a theory of the resulting forms of biological sub-citizenship. This theory builds on other studies that have already sought to complement and complicate the concept of biological citizenship with attention to the globally uneven experience and embodiment of bioinequalities. Focused on the unevenly embodied sequelae of austerity, the proceeding theorization of biological sub-citizenship is developed in three stages of review and conceptualization: 1) Biological sub-citizenship through exclusion and conditionalization; 2) Biological sub-citizenship through extraction and exploitation; and 3) Biological sub-citizenship through financialized experimentation. In conclusion the paper argues that the analysis of biological sub-citizenship needs to remain open-ended and relational in order to contribute to socially-searching work on the social determinants of health.

Enhancing health care equity with Indigenous populations: evidence-based strategies from an ethnographic study

BACKGROUND

Structural violence shapes the health of Indigenous peoples globally, and is deeply embedded in history, individual and institutional racism, and inequitable social policies and practices. Many Indigenous communities have flourished, however, the impact of colonialism continues to have profound health effects for Indigenous peoples in Canada and internationally. Despite increasing evidence of health status inequities affecting Indigenous populations, health services often fail to address health and social inequities as routine aspects of health care delivery. In this paper, we discuss an evidence-based framework and specific strategies for promoting health care equity for Indigenous populations.

METHODS

Using an ethnographic design and mixed methods, this study was conducted at two Urban Aboriginal Health Centres located in two inner cities in Canada, which serve a combined patient population of 5,500. Data collection included in-depth interviews with a total of 114 patients and staff (n = 73 patients; n = 41 staff), and over 900 h of participant observation focused on staff members' interactions and patterns of relating with patients.

RESULTS

Four key dimensions of equity-oriented health services are foundational to supporting the health and well-being of Indigenous peoples: inequity-responsive care, culturally safe care, trauma- and violence-informed care, and contextually tailored care. Partnerships with Indigenous leaders, agencies, and communities are required to operationalize and tailor these key dimensions to local contexts. We discuss 10 strategies that intersect to optimize effectiveness of health care services for Indigenous peoples, and provide examples of how they can be implemented in a variety of health care settings.

CONCLUSIONS

While the key dimensions of equity-oriented care and 10 strategies may be most optimally operationalized in the context of interdisciplinary teamwork, they also serve as health equity guidelines for organizations and providers working in various settings, including individual primary care practices. These strategies provide a basis for organizational-level interventions to promote the provision of more equitable, responsive, and respectful PHC services for Indigenous populations. Given the similarities in colonizing processes and Indigenous peoples' experiences of such processes in many countries, these strategies have international applicability.