Structural Violence and Structural Vulnerability Within the Risk Environment: Theoretical and Methodological Perspectives for a Social Epidemiology of HIV Risk Among Injection Drug Users and Sex Workers

DOI: 10.1007/978-94-007-2138-8_10 In book: Rethinking Social Epidemiology, pp.205-230

ABSTRACT The transmission of HIV is shaped by individual-environment inter­actions. Social epidemiologic approaches thus seek to capture
the dynamic and reciprocal relationships of individual-environment interactions in the production and reduction of risk. This
presents considerable methodological, theoretical and disciplinary challenges. Drawing upon four research case studies, we
consider how methods and concepts in the social and epidemiologic sciences might be brought together towards understanding
HIV risk as an effect of social, cultural and political condition. The case studies draw upon different combinations of methods
(qualitative, ethnographic and quantitative) and disciplines (sociology, anthropology and epidemiology) in different social
contexts of HIV vulnerability (street settings in Russia, Serbia and North America and a cross-border setting in Mexico) among
a range of marginalised high-risk populations (injection drug users and female and transvestite sex workers). These case studies
illustrate the relevance of the social science concepts of “structural violence” and “structural vulnerability” for a social
epidemiology of HIV risk. They also explore how social epidemiologic work can benefit from the mixing of social science methods
and theories. We contend that social epidemiology cannot advance in its understanding of structural vulnerability without
embracing and relying upon ethnographic and qualitative approaches. We put ­forward the linked concepts of “structural violence,”
“structural vulnerability” and “risk environment” as building blocks for a theory-informed social epidemiology of HIV risk
among marginalised populations.

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Available from: Steffanie A Strathdee, Sep 29, 2015
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    • "Building on the idea of structural violence first proposed by Johan Galtung (Galtung, 1969; Galtung & Höivik, 1971) and later popularized by Paul Farmer (Farmer, 2004), Quesada, Hart, and Bourgois (2011) posit that structural vulnerability invokes not only political economic factors, but an array of cultural and social factors in producing harm and duress. This positioning imposes patterned physical and emotional suffering on specific groups through economic, cultural, class-based, and gendered forms of discrimination that perversely become internalized into the subjectivities of the very groups who are relegated to a depreciated position (Quesada et al., 2011; Rhodes et al., 2011). Our data suggest that sex worker couples in this context internalize these external structures with profound consequences for their relationships and emotional health. "
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    ABSTRACT: Partner communication about HIV sexual risk behaviors represents a key area of epidemiologic and social importance in terms of infection acquisition and potential for tailored interventions. Nevertheless, disclosing sexual risk behaviors often presents myriad challenges for marginalized couples who engage in stigmatized behaviors. Using qualitative data from a social epidemiology study of risk for HIV and other sexually transmitted infections (STIs) among female sex workers and their intimate, non-commercial male partners along the Mexico-U.S. border, we examined both partners' perspectives on sex work and the ways in which couples discussed associated HIV/STI risks in their relationship. Our thematic analysis of individual and joint interviews conducted in 2010 and 2011 with 44 couples suggested that broader contexts of social and economic inequalities profoundly shaped partner perspectives of sex work. Although couples accepted sex work as an economic contribution to the relationship in light of limited alternatives and drug addiction, it exacted an emotional toll on both partners. Couples employed multiple strategies to cope with sex work, including psychologically disconnecting from their situation, telling "little lies," avoiding the topic, and to a lesser extent, superficially discussing their risks. While such strategies served to protect both partners' emotional health by upholding illusions of fidelity and avoiding potential conflict, non-disclosure of risk behaviors may exacerbate the potential for HIV/STI acquisition. Our work has direct implications for designing multi-level, couple-based health interventions.
    Social Science [?] Medicine 06/2013; 87:1-8. DOI:10.1016/j.socscimed.2013.03.010 · 2.89 Impact Factor
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    • "Similarly, trafficking laws in India, such as Immoral Traffic Prevention Act, 1986, are used by law enforcement authorities to arrest, harass, and abuse women in sex work (Lawyers Collective, 2003; World Health Organization [WHO], 2005), further exacerbating the stigma and discrimination associated with sex work and HIV in India (Mawar, Sahay, Pandit, & Mahajan, 2005) and limiting women's access to HIV preventive health services. Despite increasing evidence in research that it is the interplay between individual, sociocultural, structural–environmental factors that enhances women's vulnerability to HIV infection (Blankenship & Koester, 2002; Bletzer, 2003; Esther-Epele, 2002; Gupta & Weiss, 1993; Rhodes et al., 2012), most HIV prevention programs reaching out to women sex workers in India are focused on the individual-level risk factors, with emphasis on condom promotion and distribution as the HIV risk reduction strategy, ignoring the role sociocultural and economic factors play in determining women's health-seeking practices. The most common HIV prevention programs in India are the National AIDS Control Program (NACP), implemented by the NGOs with funding received from National AIDS Control Organization (NACO). "
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    ABSTRACT: Based on my 7 months of ethnographic research with "flying" or mobile female sex workers (FSWs) in the eastern metropolitan city of Kolkata, India, I argue that the human immunodeficiency virus (HIV) prevention programs have a limited outreach and impact within the community because of the fundamental differences in how the nongovernmental organizations (NGOs) staff and flying FSWs perceive the risk of HIV. This article examines flying FSWs perceptions of HIV risk and the NGOs sexual health outreach services. Further, the implications for HIV prevention programs and social work practice are discussed.
    Affilia 04/2013; 29(2):206-223. DOI:10.1177/0886109913516450 · 0.65 Impact Factor
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    • "Mixed methods approaches have also been used to examine research questions concerning broader trends in illicit drug use and injection-related health outcomes, such as an emerging wave of crack use in one community (Clatts, Welle, Goldsamt, & Lankenau, 2002), an emerging HIV epidemic associated with drug injection (Barcal, Schumacher, Dumchev, & Moroz, 2005), and relationships between patterns of illicit drug trade and IDU health outcomes (Ciccarone & Bourgois, 2003; Roy et al., 2012; Wood, Stoltz, Li, Montaner, & Kerr, 2006). Despite this developing body of mixed methods IDU research, few studies describe in great detail the logistics of the actual mixed methods procedures used, with the exception of Rhodes et al. (2012) who explore mixing methods and utilizing social science theory as a way to examine structural vulnerability and HIV risk and Wagner et al. (2012) who closely examine incongruent findings in mixed methods research. The current paper focuses solely on the details of our methodological procedures and scientific " value-added " when mixing methods in IDU research. "
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    ABSTRACT: Research with injection drug users (IDUs) benefits from interdisciplinary theoretical and methodological innovation because drug use is illegal, socially sanctioned and often hidden. Despite the increasing visibility of interdisciplinary, mixed methods research projects with IDUs, qualitative components are often subordinated to quantitative approaches and page restrictions in top addiction journals limit detailed reports of complex data collection and analysis logistics, thus minimizing the fuller scientific potential of genuine mixed methods. We present the methodological logistics and conceptual approaches of four mixed-methods research projects that our interdisciplinary team conducted in San Francisco with IDUs over the past two decades. These projects include combinations of participant-observation ethnography, in-depth qualitative interviewing, epidemiological surveys, photo-documentation, and geographic mapping. We adapted Greene et al.'s framework for combining methods in a single research project through: data triangulation, methodological complementarity, methodological initiation, and methodological expansion. We argue that: (1) flexible and self-reflexive methodological procedures allowed us to seize strategic opportunities to document unexpected and sometimes contradictory findings as they emerged to generate new research questions, (2) iteratively mixing methods increased the scope, reliability, and generalizability of our data, and (3) interdisciplinary collaboration contributed to a scientific "value added" that allowed for more robust theoretical and practical findings about drug use and risk-taking.
    The International journal on drug policy 01/2013; 24(2). DOI:10.1016/j.drugpo.2012.12.004 · 2.54 Impact Factor
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