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


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
    • "An ecological model of violence prevention takes into account not only individual level characteristics (such as gender), but also social networks (of family and peers) and community contexts (such as poverty), to identify appropriate targets for intervention. For example, youths residing in poor urban communities across the north-south socioeconomic divide are at increased risk of ETV, both as witnesses and as victims (Buka et al., 2001; Rhodes et al., 2012; United Nations [UN], 2003). Social disorganization theory identifies that neighborhood factors such as resource deprivation, family disruption, and residential mobility contribute to diminished social controls and a community's inability to maintain common values through informal and formal social networks (Kawachi et al., 1999; Sampson and Groves, 1989). "
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    ABSTRACT: Previous research has demonstrated that exposure to violence (ETV) is a serious concern across the north-south socioeconomic divide. While studies have found that social support is a protective factor for youth exposed to violence and trauma, little is known about the impact of trauma symptoms on forming and maintaining social relationships which are key to accessing a vital social resource that fosters resilience in youth experiencing trauma symptomatology. Building on previous models that examine the impact of neighborhoods on exposure to violence and trauma, the current study examines the impact of neighborhood disorganization on ETV among youth and ETV's effects on trauma symptoms and social relationships. Data were collected on 2242 juvenile justice-involved youth with behavioral health issues in 11 urban and rural counties in the Midwestern United States. Using structural equation modeling (SEM), our data demonstrated that living in highly disorganized neighborhoods was associated with higher levels of ETV and that ETV was positively associated with trauma symptoms. Mediational analysis showed that trauma symptoms strongly mediated the effect of ETV on social relationships. Freely estimating structural paths by gender revealed that hypothesized associations between these variables were stronger for females than males. Findings here highlight the need to provide trauma-informed care to help youth to build and maintain social relationships. Identification and treatment of trauma symptoms that is culturally informed is a critical first step in ensuring that identified protective factors in local contexts, such as social relations and social support, have opportunities to minimize the impact of ETV among youth across northern and southern nations.
    No preview · Article · Oct 2015 · Social Science [?] Medicine
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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.
    Full-text · Article · Jun 2013 · Social Science [?] Medicine
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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.
    Full-text · Article · Apr 2013 · Affilia
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