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Cultural epidemiology: Conceptual framework and current directions of an interdisciplinary field

January 2018
Glasnik Etnografskog instituta 66(2):245-253

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Cultural epidemiology is an interdisciplinary field based on principles and methods of medical anthropology and classical epidemiology. Its contribution to health research results from a focus on illness, distinct from the disease orientation of classical epidemiology. Though rooted in the influential illness explanatory model framework, current developments in the field of cultural epidemiology refer more explicitly to determinants of health and illness beyond explanatory models based on frameworks of critical medical anthropology. This rethinking of cultural epidemiology acknowledges the need for research to consider domains of a revised Outline for Cultural Formulation referring to cultural identity, key social relations, and the impact of political economy and other structural features of society. In addition to this current work in cultural psychiatry, two other areas of research remain active: public health studies of professional and community determinants of vaccine acceptance and research on assessment and study of stigma as a clinically significant feature of illness experience, providing a clinical complement to more mainstream community studies of stigma.

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DOI: https://doi.org/10.2298/GEI1802245W

UDC 316.734:39:572.028

Review article

245

Mitchell G. Weiss

Professor Emeritus, Swiss Tropical and Public Health Institute - Basel, and

University of Basel, Switzerland

mitchell-g.weiss@unibas.ch

Cultural Epidemiology: Conceptual Framework and

Current Directions of an Interdisciplinary Field

Cultural epidemiology is an interdisciplinary field based on principles and methods of

medical anthropology and classical epidemiology. Its contribution to health research results

from a focus on illness, distinct from the disease orientation of classical epidemiology.

Though rooted in the influential illness explanatory model framework, current developments

in the field of cultural epidemiology refer more explicitly to determinants of health and

illness beyond explanatory models based on frameworks of critical medical anthropology.

This rethinking of cultural epidemiology acknowledges the need for research to consider

domains of a revised Outline for Cultural Formulation referring to cultural identity, key

social relations, and the impact of political economy and other structural features of society.

In addition to this current work in cultural psychiatry, two other areas of research remain

active: public health studies of professional and community determinants of vaccine

acceptance and research on assessment and study of stigma as a clinically significant feature

of illness experience, providing a clinical complement to more mainstream community

studies of stigma.

Key words: cultural epidemiology, illness and disease, illness explanatory models, stigma,

vaccine acceptance, Outline for Cultural Formulation

Културна епидемиологија: концептуални оквир и актуелни

правци интердисциплинарног поља

Културна епидемиологија је интердисциплинарно поље засновано на принципима и

методима медицинске антропологије и класичне епидемиологије. Њен допринос

истраживањима здравља исходи из усредсређености на концепт болести, који је

другачији од концепта обољења, ка коме се оријентише класична епидемиологија.

Иако укорењени у оквиру утицајног експланаторног модела болести, савремени

токови на пољу културне епидемиологије експлицитније реферишу на детерминанте

здравља и болести које превазилазе експланаторне моделе базиране у оквирима

критичке медицинске антропологије. Овакво преиспитивање културне епидемиологије

признаје да постоји потреба да истраживања узму у обзир делове ревидираног Нацрта

за културно формулисање који се односе на културни идентитет, кључне друштвене

односе, утицај политичке економије и других структурних одлика друштва. Поред

постојећег рада на пољу културне психијатрије, још су две истраживачке области

активне: истраживања професионалних и друштвених детерминанти прихватања

вакцинације у оквиру јавног здравља; истраживања на процени стигме као клинички

 Гласник Етнографског института САНУ LXVI (2); 245-253 

246

значајне инстанце за искуство болести која доприносе креирању клиничке допуне за

више мејнстрим друштвена истраживања стигме.

Кључне речи: културна епидемиологија, болест и обољење, експланаторни модел

болести, стигма, прихватање вакцина, Нацрт за културно формулисање

Background

Conceived as an interdisciplinary field, cultural epidemiology developed a

framework and methods based on principles and practices of medical anthropology

and classical epidemiology. Cultural epidemiology has been defined as the study of

locally valid representations of illness and their distribution. These representations

are elaborated by variables and narrative description with reference to illness expe-

rience, perceived causes of illness and illness behaviour. The integration, not just

mixing, of quantitative epidemiological methods and qualitative ethnographic

methods is a priority, and specialized techniques have been developed for that

(Mitchell G. Weiss 2001; 2017). A fundamental principle of medical anthropology,

acknowledging the distinction of disease and illness, is central to the rationale and

definition of cultural epidemiology.

This distinction of disease and illness, which has become a fundamental

principle on which medical anthropology and cultural epidemiology are grounded,

arose from disenchantment with the technological and increasingly industrial orien-

tation of medical practice in the United States in the 1970s. Much of the work in the

early development of medical anthropology, responding to practical needs and aca-

demic interests, was a product of clinical experience of anthropologists and clini-

cian-anthropologists (Chrisman and Maretzki 1982). John Cassell, a practicing in-

ternist and public health researcher, initially developed and elaborated the distinc-

tion of illness from disease based on concerns about public dissatisfaction with

medical care and the realization that the most significant improvements in the

health of populations could not be explained as a simple product of technological

advances enabling improved clinical treatment of disease. He also argued that the

focus on disease in medical training was a source of later frustration for doctors af-

ter they left academic training and began to practice medicine. The focus on disease

left them unprepared to respond to patients’ concerns about their illnesses. Further-

more, he regarded the assumption that illness and disease are the same as a cultural

artefact, and he reasoned that curing and healing were therefore different functions

as well. He explained this proposition in a 1976 paper as follows:

„There is a distinction between the disease of an organ of the body

and the illness of the whole man. We certainly base many of our com-

plaints about doctors on just such a difference. We say, “All the doctor

seems to care about are my kidneys; he doesn't care about me”—and

we know what we mean, or think we do. From this point on, let us use

the word “illness” to stand for what the patient feels when he goes to

the doctor and “disease” for what he has on the way home from the

doctor's office. Disease, then, is something an organ has; illness is

something a man has.“ (Cassell 1976, 27)

 M. G. Weiss, Cultural Epidemiology: Conceptual Framework and Current Directions... 

247

Over time, this distinction has been refined with regard to theory in medical

anthropology without fundamentally altering the point (Hahn 1984). In current us-

age, disease has become a proxy for broader professional considerations beyond the

“disease of an organ of the body” to also include biochemical processes, injuries

and other professionally conceived explanations of health problems as disorders.

Definitions of classical epidemiology as a basic science of public health

typically refer to the occurrence and determinants of disease in a population. Alt-

hough nontechnical definitions of epidemiology refer to the study of the causes, dis-

tribution and control of disease in populations, technical accounts are more careful

to make broader professional interests explicit, expanding the concept of disease to

“health-related states or events in specified populations, including the study of the

determinants influencing such states, and the application of this knowledge to con-

trol the health problems” (Porta 2014). The WHO definition glosses “health-related

states or events” as “diseases” in its online definition.

Cultural epidemiology should be distinguished from classical epidemiology

insofar as it is an epidemiology of illness—not an epidemiology of disease, disorder

or other entity derived from professionally defined systems of classification. It is

concerned with the illness-related experience, meaning and behaviour from the van-

tage point of the people directly concerned (including patients) or otherwise in-

volved (e.g., family, colleagues, community and caretakers). The epidemiology of

tuberculosis as a disease is a different matter from the cultural epidemiology of TB

illness. As Cassell (1976, 32) pointed out in his classic account noted above, “in tu-

berculosis, where the disordered feelings, disconnectedness from the society, and

numerous other ramifications of the disease are widespread and pervasive, curing—

killing the tubercle bacillus—represents only part of returning the patient to health”.

Measuring the incidence and prevalence of TB does not tell us how common the

features of illness actually are, or whether such problems among the patterns of dis-

tress explain why people wait too long before coming for treatment or fail to com-

plete their prescribed treatment. Such questions are matters that the methods of cul-

tural epidemiology are better able to consider.

The instruments and approach of cultural epidemiology were initially con-

ceived in the Harvard medical anthropology programme in the 1980s, where the

framework of Kleinman’s illness explanatory models and motivating interest in cul-

tural psychiatry were highly influential (Kleinman 1980, 1977). Developed with re-

search partners, the instruments were explanatory model interviews. Because they

were concerned with locally meaningful accounts of illness, rather than profession-

ally valid accounts of disease, the concepts and categories that were counted had to

be adapted according to the cultural setting and particular health problems to be

studied. Categories for coding perceived causes in a study of childhood diarrhoea in

Central Thailand concerned with use of oral rehydration solution were necessarily

different from suitable categories for an interview intended for research on patients

with depression in India. An adaptable framework, however, enabled categorical

coding for quantitative analysis of responses to questions about illness experience,

perceived causes and help seeking. The interview was also designed to elicit exten-

sive narrative accounts of illness and study-specific interests for qualitative analy-

 Гласник Етнографског института САНУ LXVI (2); 245-253 

248

sis. A set of analytic methods were developed to relate qualitative and quantitative

data using software available at the time and enhanced over the years, most recently

using tablet devices for recording and time stamps for first-level qualitative coding

(Giduthuri et al. 2014).

Respondents’ emic account of illness that are the focus of cultural epidemi-

ological study may be contrasted with etic data grounded in professional disease

explanatory models. The instruments based on that framework were commonly

called EMIC interviews (Explanatory Model Interview Catalogue), referring both to

the priority of their emic orientation and acknowledgement that such interviews

were adapted and collectively constitute a catalogue rather than a single fixed in-

strument. Conceived in the framework of clinical medical anthropology, these

EMIC interviews were tools for studying the cultural epidemiology of illness ex-

planatory models, providing useful information that complemented findings from

both classical epidemiology and more extensive ethnographies based on traditional

anthropological methods. The approach to development of EMIC interviews was

firmly rooted in Kleinman’s illness explanatory model framework, based on “no-

tions about an episode of sickness and its treatment that are employed by all those

engaged in the clinical process” (Kleinman 1980, 105).

For clinician anthropologists, explanatory models were especially appeal-

ing because they were concerned with the way culture affected individuals with par-

ticular problems, instead of presenting a homogenized view of patients based on

reference to a simplistic set of cultural characteristics that might too easily replace

the individuality of patients with a stereotype. Cecil Helman was a general practi-

tioner in North London and an anthropologist who taught in a graduate programme.

He authored an influential textbook of medical anthropology in which he made the

point that “one cannot make broad generalizations about the members of any human

group without taking into account the fact that differences among the group’s mem-

bers may be just as marked as those between the members of different cultural

groups” (Helman 2007, 4). A patient-centred explanatory model approach, focusing

on illness episodes, was well-suited for enabling use of anthropological insights in

clinical practice. Cultural epidemiology provided a means of documenting patterns

of illness that both clarified ethnomedical concepts of a study group and enabled

study of practical implications.

To explain its theoretical grounding and motivation for further developing

the approach, it is important to acknowledge the two branches of medical anthro-

pology that began developing in parallel in the 1970s. Both were concerned with

limitations imposed by the dominant disease models and practices in biomedicine

and the health systems they were a part of. In contrast to explicit clinical and public

health priorities that medical anthropology was contributing to, another approach

was also emerging, closer to traditional anthropological study of medical practices

and health systems with a focus on the health impact of political and economic

structural features of society. This critical medical anthropology (CMA) was initial-

ly conceived as an approach to transcend microanalytic study interests and pursue

an alternative based on macroanalytic considerations. Although explanatory models

were relevant for microanalytic studies of illness episodes, CMA study of health

 M. G. Weiss, Cultural Epidemiology: Conceptual Framework and Current Directions... 

249

systems relied on conceptual frameworks based on political economy, equity and

questions of power and access to resources (Janzen 1978; Baer, Singer, and Johnsen

1986; Singer, Baer, and Lazarus 1990). The explanatory model framework was

acknowledged as inadequate to address such questions (Kleinman 1997).

Topical interests of the field

Recent reviews of cultural epidemiology and explanatory models in psy-

chiatry provide an overview of topical interests with particular attention to research

on cultural psychiatry and mental health topics (Mitchell G. Weiss 2018; 2017).

They refer to studies in India of depression, schizophrenia, neurasthenia and sui-

cide. The research includes clinical ethnographic accounts elaborating ethnomedical

concepts of mental illness (Mitchell G. Weiss et al. 1988), and considers their rela-

tionship to psychiatric diagnoses (M.G. Weiss, Raguram, and Channabasavanna

1995). Cultural epidemiological study of family survivors of suicide suggested the

value of a sociocultural autopsy based on the EMIC framework to complement cur-

rent mainstream approaches to psychological autopsy that overemphasize the ex-

planatory value of psychiatric diagnoses at the expense of social relationships and

societal structural factors (Parkar, Nagarsekar, and Weiss 2009). Stigma has been

an enduring interest of cultural epidemiology (Raguram et al. 2004).

Infectious disease studies highlight a set of research interests that were al-

ready clear from the outset. In fact, the first EMIC interview was developed for a

study of leprosy and mental health, and it examined illness explanatory models of

people with leprosy in Mumbai (M.G. Weiss et al. 1992). Cultural epidemiological

studies of TB have examined the role of gender differences in the experience (pat-

terns of distress) and meaning (perceived causes) of TB in a group of studies in

Bangladesh, India, Malawi and Colombia (M.G. Weiss et al. 2008), and effects of

features of illness explanatory models that account for delayed help seeking

(Gosoniu et al. 2008). Studies of TB-related stigma have considered both communi-

ty views and the experience of patients (Atre et al. 2011; Somma et al. 2008). Addi-

tional cultural epidemiological studies of infectious diseases have focused on other

neglected tropical diseases, including leprosy and Buruli ulcer.

Current activities and next steps

Three areas of current research are extending the scope and framework of

cultural epidemiological principles and methods. Topics include studies of vaccine

acceptance based on awareness, priority and use with a focus on both health care

providers and community residents. This work is based on vaccine acceptance and

anticipated acceptance studies of oral cholera vaccine in Zanzibar, Kenya and DR

Congo (Schaetti et al. 2013; Sundaram et al. 2016), and a study of influenza vaccine

acceptance during the 2009 influenza pandemic in Pune, India (Sundaram et al.

2015). More recently, a study of influenza vaccination of pregnant women to pro-

tect them and their newborn infants has been developed for WHO. Unique chal-

 Гласник Етнографског института САНУ LXVI (2); 245-253 

250

lenges of limited vaccine coverage with HPV vaccine for adolescents indicate pro-

spects for further study.

Health-related stigma has become an important topic in public health. Most

research, however, studies stigmatizing views in communities towards stigmatized

diseases. Mental health problems, leprosy, HIV/AIDS and TB are common exam-

ples. The near-exclusive focus of research on stigma in the community, however,

ignores relevant aspects of stigma in the clinic. Our work suggests that experience

and concerns with clinically significant stigma should become a more regular con-

sideration in the course of clinical assessment. Distinguishing the impact of experi-

ence as a target of previously enacted stigma from currently anticipated and ongo-

ing self-stigmatization is a relevant consideration for study of clinical stigma

(Mitchell G. Weiss 2008). Methods for analysing, documenting and comparing the

magnitude of stigma and qualitatively assessing stigma narratives have been refined

to improve prospects for comparing stigma assessments. Such clinical stigma stud-

ies are needed to complement well-established community stigma research in the

fields of sociology, social psychology and population-based studies in psychiatry

that support anti-stigma campaigns. A focus on clinically significant stigma over-

comes limitations of labelling-based formulations by applying principles of cultural

psychiatry to study of illness experience, which includes experience of stigma.

Development of the Outline for Cultural Formulation (OCF) for psychiatric

assessment in the DSM-IV represented an important contribution of cultural psy-

chiatry to clinical assessment (American Psychiatric Association 1994). Although

experience with the OCF has been limited to psychiatry, the framework is relevant

for other areas of medical practice and research. A recently proposed revision of the

OCF based on experience of our cultural epidemiology research group extends the

scope of clinical medical anthropological considerations (Paralikar, Deshmukh, and

Weiss In Press). This revised OCF provides an appropriate guide for clinical as-

sessment and for cultural epidemiological research to support use of the OCF. The

following is the proposed revised structure: cultural identity (domain I); illness ex-

planatory model (domain II); key social interpersonal relations (domain III); and

relevant societal structural features acknowledging the potential impact of social

status and political economy (domain IV). This revision is mindful of the potential

value of attending to clinically significant issues beyond both disease and illness as

a feature of both clinical assessment and research. Further research in cultural epi-

demiology should be more explicit in their attention to domains I, III and IV of this

formulation to support documentation and use of the revised OCF. This will thereby

enable needed attention not only to health problems but also to the person, social

stressors and supports, and the opportunities and constraints imposed by structural

features of society.

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Примљено / Received: 05. 02. 2018.

Прихваћено / Accepted: 03. 05. 2018.

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Jan 2025
Indian J Community Med

There is growing evidence from developed countries that type 2 diabetes stigma has been prevalent. However, whether or not type 2 diabetes has a social stigma in India has not been explored. Against this background, a study was attempted to clarify type-2 diabetes-related stigma among general community members. A cross-sectional community-based survey using a locally adapted Explanatory Module Interview Catalog was conducted among 100 randomly selected general community members who did not have diabetes from slum pockets of Pune city. The stigma index was computed based on the responses of stigma indicators and the internal consistency assessed. In addition, based on the mean prominence values, socio-cultural group characteristics were analyzed across stigma indicators. Further, multivariate logistic regression assessed the relationship between socio-demographic characteristics as predictors and stigma indicators as outcome variables. General community members reported widespread awareness regarding type-2 diabetes. More than half of the respondents perceived that diabetes would be a fatal disease without any outside treatment. The resultant stigma index was 7.22 (Cronbach’s alpha = 0.75). The milder stigma for type-2 diabetes was revealed through the preference to hide, problems in arranging marriages, difficulties in ongoing marriages, and discrimination instances at the workplace. Adjusted logistic regression (AOR) across stigma indicators showed a tendency to hide diabetes across marital status (AOR = 8.39) and difficulty forming marriage alliances across religions (AOR = 3.10). Documented socio-cultural features of stigma should be considered priorities for action to mitigate its negative influence on the physical health and emotional well-being of persons who have diabetes.

Sociocultural features of lifestyle modifications among TB–diabetes comorbid patients in Satara, India and its implications for planning self-management interventions for TB–diabetes comorbid patients

Article

Full-text available

Sep 2024
Discov Public Health

Background Lifestyle modifications (LM) are crucial in managing comorbid Tuberculosis (TB) and Diabetes Mellitus (DM) patients, significantly impacting treatment outcomes and overall health. In view of this, a study was conducted to clarify sociocultural features associated with LM among TB–diabetes comorbid patients. Methods A cross-sectional descriptive study among randomly selected 180 adult TB–diabetes-comorbid-patients was conducted using a semi-structured interview schedule. Mann–Whitney-U-test was used to examine differences in means between patterns of distress (PDs) and perceived causes (PCs) regarding TB and Diabetes for two identified LM strategies among comorbid patients. Stepwise logistic regression was used to study factors associated with these LM strategies. Results TB–diabetes-comorbid-patients reporting physical symptoms as PDs preferred to follow the LM-1 strategy for TB and LM-2 for Diabetes. In contrast, patients reporting health-illness-injury-related causes follow LM-2 for TB and LM-1 for Diabetes. Further patients reporting hypertension for Diabetes (AOR = 2.916, 95% CI 0.9262–9.1788) and concerns-about-the-course-of-TB-illness (AOR = 3.746, 95% CI 1.4683–9.5593) as PDs were 3–4 times more likely to follow LM-1. While those reporting prior illnesses (AOR = 4.255, 95% CI 1.3941–12.9837) and sanitation (AOR = 5.242, 95% CI 1.2028–22.8446) as PCs for TB were 4–5 times follow LM-2. Patients who perceived consumption of alcohol as PCs of Diabetes were 10 times more likely to stop addictions (AOR = 9.680, 95% CI 2.5555–36.6639) and follow the LM-2 strategy. Conclusion Given significant associations of sociocultural features with LM strategies, consideration of sociocultural features vis-à-vis these strategies is indispensable for managing TBDM comorbidity, emphasizing the need for developing comprehensive, patient-centred self-management interventions to enhance adherence and improve health outcomes.

Making Cultures Count: Transforming Indigenous Health Data in Australia

Thesis

Full-text available

Nov 2020

Sarah C Bourke

To date, national statistics have placed Indigenous Australians and their health in constant comparison with non-Indigenous Australians. This has generated a deficit discourse, reinforcing the notion of an ‘Indigenous problem’ in Australian society. In response, Indigenous and non-Indigenous health researchers have worked together to build momentum for ‘strengths-based’ research approaches, advocating for the positive influence which Indigenous cultures have on health outcomes, and the need to quantify this relationship at the population level to challenge the deficit discourse. This thesis focuses on the development of the first national survey to measure this relationship, designed and owned by Indigenous Australians — the Mayi Kuwayu National Study of Aboriginal and Torres Strait Islander Wellbeing. Using an Indigenist research approach, this thesis navigates the influence of social, political, and historical factors on the development of the Mayi Kuwayu Study’s methodology and survey structure. It draws on multi-sited observations of focus groups across Australia and interviews with its key researchers and Indigenous community stakeholders conducted between May 2017 and November 2018. This thesis shows that the Mayi Kuwayu Study researchers strategically mobilised the concept of culture within their epidemiological framework. The focus groups they conducted with Indigenous community members helped to establish the credibility and validity of the metrics used in their survey. The Indigeneity of the researchers and stakeholders was seen to mediate this operational translation of culture from its lived experience. I found that the Indigenous leadership and ownership of the study altered the epidemiological research process and enhanced its potential to produce meaningful data, empowering Indigenous Australian communities and decolonising the wider Indigenous health narrative. While the survey’s ability to ‘save’ culture was limited, it was able to maintain a sensitivity to cultural diversity, and demonstrated that cultural determinants of health is a promising, strengths-based framework for large-scale epidemiological research.

Explaining patient delay in healthcare seeking and loss to diagnostic follow-up among patients with presumptive tuberculosis in Tanzania: a mixed-methods study

Article

Full-text available

Apr 2019
BMC HEALTH SERV RES

Background Delay in healthcare seeking and loss to diagnostic follow-up (LDFU) contribute to substantial increase in tuberculosis (TB) morbidity and mortality. We examined factors, including perceived causes and prior help seeking, contributing to delay and LDFU during referral to a TB clinic among patients with presumptive TB initially seeking help at the pharmacies in Dar es Salaam Tanzania. Methods In a TB clinic, a semi-structured interview based on the explanatory model interview catalogue (EMIC) framework for cultural epidemiology was administered to presumptive TB patients enrolled at pharmacies during an intervention study. We assessed delay in seeking care at any medical care provider for a period of ≥3 weeks after the onset of symptoms, LDFU during referral (not reaching the TB clinic), and LDFU for three required TB clinic visits among the presumptive and confirmed TB patients. Logistic regression models were used to assess factors associated with delay and LDFU. Results Among 136 interviewed patients, 86 (63.2%) were LDFU from pharmacies and TB clinic while 50 (36.8%) were non-LDFU. Out of 136 patients 88 (64.7%) delayed seeking care, of whom 59 (67%) were females. Among the 86 (63.2%) patients in LDFU group, 62 (72.1%) delayed seeking care, while among the 50 (36.8%) non-LDFU, 26 (52.0%) had also delayed seeking care. Prior consultation with a traditional healer (aOR 2.84, 95% CI 1.08–7.40), perceived causes as ingestion (water and food) (aOR 0.38 CI 0.16–0.89), and substance use (smoking and alcohol) (aOR 1.45 CI 0.98–2.14) were all associated with patient delay. Female gender was associated with LDFU (aOR 3.80, 95% CI 1.62–8.87) but not with delay. Other conditions as prior illness and heredity were also associated with LDFU but not delay (aOR 1.48 CI 1.01–2.17). Conclusion Delay and LDFU after referral from the pharmacies were substantial. Notable effects of diagnosis and female gender indicate a need for more attention to women’s health to promote timely and sustained TB treatment. Public awareness to counter misconceptions about the causes of TB is needed.

Illness experiences and mental health challenges associated with female genital schistosomiasis in Cameroon: a gender analysis

Article

Full-text available

Mar 2024

Background This paper highlights the role of cultural and structural gaps that shape illness experiences of women with manifestations of female genital schistosomiasis (FGS) and their impacts upon mental well-being. Methods Using ethnography, case study narrative accounts of women manifesting symptoms of FGS, as well as interviews with health workers within FGS-endemic rural fishing communities in Cameroon, we present experiences of women affected by FGS, alongside information on FGS health service provision. Results Our results show how gendered power dynamics in decision making, gendered experiences around menstrual health and structural gaps in service provision, combine and lead to poor mental well-being. Subfertility brings a heavy psychosocial toll from external blame and rejection, exacerbated by internalised stigma and the challenge of not being able to fulfil cultural and gendered social norms. Conclusions Gender analysis is key to developing context-embedded understanding and addressing FGS-related challenges. With context-specific experiences demonstrating FGS comorbidity with mental ill health, there is a need to prioritise mental health integration at policy level through a person-centred approach. Furthermore, to address stigma and discrimination, campaigns to raise awareness in Cameroon, and beyond, are needed. Contexte Cet article met en évidence le rôle des lacunes culturelles et structurelles qui façonnent les expériences des femmes atteintes de schistosomiase génitale féminine (SGF) et leur impact sur le bien-être mental. La méthode À l'aide de l'ethnographie, de récits d'études de cas de femmes présentant des symptômes de schistosomiase génitale féminine, et d'entretiens avec des agents de santé au sein de communautés de pêcheurs ruraux endémiques de la schistosomiase génitale féminine au Cameroun, nous présentons les expériences des femmes touchées par le SGF, ainsi que des informations sur les services de santé liés au SGF. Résultats Nos résultats montrent comment la dynamique du pouvoir dans la prise de décision, les expériences de la santé menstruelle et les lacunes structurelles dans la fourniture de services, interagissent et conduisent à un manque de bien-être psychologique. La sous-fécondité entraîne un lourd fardeau psychosocial du fait du blâme et de rejet externes auxquelles sont assujetties les personnes souffrant de la maladie, ce qui est exacerbé par la stigmatisation intériorisée et le défi que représente leur incapacité à respecter les normes sociales culturelles et sexospécifiques. Conclusion L'analyse de genre est essentielle pour développer une compréhension intégrée au contexte et pour relever les défis liés aux SGF. les défis liés à l'ESF. Avec des expériences spécifiques au contexte démontrant la comorbidité de la FGS avec la mauvaise santé mentale, il est nécessaire de donner la priorité à l'intégration de la santé mentale au niveau politique par le biais d'une approche centrée sur la personne. l'intégration de la santé mentale au niveau politique par une approche centrée sur la personne. En outre, pour lutter contre la stigmatisation et la stigmatisation et la discrimination, des campagnes de sensibilisation sont nécessaires au Cameroun et au-delà. Antecedentes En este documento se pone de relieve el papel de las brechas culturales y estructurales que dan forma a las experiencias de enfermedad de las mujeres con manifestaciones de Esquistosomiasis Genital Femenina (EGF), y sus impactos en el bienestar mental. Método Utilizando la etnografía, estudios de caso mediante relatos narrativos de mujeres que manifiestan síntomas de EGF y entrevistas con trabajadores sanitarios de comunidades pesqueras rurales endémicas en Camerún, presentamos las experiencias de las mujeres afectadas por la EGF, junto con información sobre la prestación de servicios sanitarios para la EGF. Resultados Nuestros resultados muestran cómo la dinámica de poder de género en la toma de decisiones, las experiencias de género en torno a la salud menstrual y las deficiencias estructurales en la prestación de servicios se combinan y conducen a un bienestar mental deficiente. La subfertilidad conlleva un alto coste psicosocial debido a la culpa y el rechazo externos, exacerbados por el estigma interiorizado y el reto de no poder cumplir las normas culturales y de género. Conclusión El análisis de género es clave para desarrollar una comprensión integrada en el contexto y abordarlos retos relacionados con la EGF. Dado que las experiencias específicas de cada contexto demuestran la comorbilidad de las EGF con la enfermedad mental, es necesario priorizar la integración de la salud mental en las políticas a través de un enfoque centrado en la persona. Además, para hacer frente al estigma y la discriminación, son necesarias campañas de sensibilización en Camerún y en otros lugares.

Sociocultural aspects of delays in diagnosis among Tuberculosis-Diabetes Comorbid patients in Satara, India: Its implications for the implementation of the National Framework for Joint Tuberculosis-Diabetes Collaborative Activities

Article

May 2023
Indian J Tubercul

Mapping Asian American minority stress research: A bibliometric study

Article

Apr 2023

A. Hwang

Sociocultural determinants of anticipated oral cholera vaccine acceptance in three African settings: A meta-analytic approach

Article

Full-text available

Jan 2016
BMC PUBLIC HEALTH

Background Controlling cholera remains a significant challenge in Sub-Saharan Africa. In areas where access to safe water and sanitation are limited, oral cholera vaccine (OCV) can save lives. Establishment of a global stockpile for OCV reflects increasing priority for use of cholera vaccines in endemic settings. Community acceptance of vaccines, however, is critical and sociocultural features of acceptance require attention for effective implementation. This study identifies and compares sociocultural determinants of anticipated OCV acceptance across populations in Southeastern Democratic Republic of Congo, Western Kenya and Zanzibar. Methods Cross-sectional studies were conducted using similar but locally-adapted semistructured interviews among 1095 respondents in three African settings. Logistic regression models identified sociocultural determinants of OCV acceptance from these studies in endemic areas of Southeastern Democratic Republic of Congo (SE-DRC), Western Kenya (W-Kenya) and Zanzibar. Meta-analytic techniques highlighted common and distinctive determinants in the three settings. Results Anticipated OCV acceptance was high in all settings. More than 93 % of community respondents overall indicated interest in a no-cost vaccine. Higher anticipated acceptance was observed in areas with less access to public health facilities. In all settings awareness of cholera prevention methods (safe food consumption and garbage disposal) and relating ingestion to cholera causation were associated with greater acceptance. Higher age, larger households, lack of education, social vulnerability and knowledge of oral rehydration solution for self-treatment were negatively associated with anticipated OCV acceptance. Setting-specific determinants of acceptance included reporting a reliable income (W-Kenya and Zanzibar, not SE-DRC). In SE-DRC, intention to purchase an OCV appeared unrelated to ability to pay. Rural residents were less likely than urban counterparts to accept an OCV in W-Kenya, but more likely in Zanzibar. Prayer as a form of self-treatment was associated with vaccine acceptance in SE-DRC and W-Kenya, but not in Zanzibar. Conclusions These cholera-endemic African communities are especially interested in no-cost OCVs. Health education and attention to local social and cultural features of cholera and vaccines would likely increase vaccine coverage. High demand and absence of insurmountable sociocultural barriers to vaccination with OCVs indicate potential for mass vaccination in planning for comprehensive control or elimination.

Community awareness, use and preference for pandemic influenza vaccines in Pune, India

Article

Full-text available

Jun 2015

Vaccination is a cornerstone of influenza prevention, but limited vaccine uptake was a problem worldwide during the 2009-2010 pandemic. Community acceptance of a vaccine is a critical determinant of its effectiveness, but studies have been confined to high-income countries. We conducted a cross-sectional, mixed-method study in urban and rural Pune, India in 2012-2013. Semi-structured explanatory model interviews were administered to community residents (n=436) to study awareness, experience and preference between available vaccines for pandemic influenza. Focus group discussions and in-depth interviews complemented the survey. Awareness of pandemic influenza vaccines was low (25%). Some respondents did not consider vaccines relevant for adults, but nearly all (94.7%), when asked, believed that a vaccine would prevent swine flu. Reported vaccine uptake however was 8.3%. Main themes identified as reasons for uptake were having heard of a death from swine flu, health care provider recommendation or affiliation with the health system, influence of peers and information from media. Reasons for non-use were low perceived personal risk, problems with access and cost, inadequate information and a perceived lack of a government mandate endorsing influenza vaccines. A majority indicated a preference for injectable over nasal vaccines, especially in remote rural areas. Hesitancy from a lack of confidence in pandemic influenza vaccines appears to have been less of an issue than access, complacency and other sociocultural considerations. Recent influenza outbreaks in 2015 highlight a need to reconsider policy for routine influenza vaccination while paying attention to sociocultural factors and community preferences for effective vaccine action.

Developing and Validating a Tablet Version of an Illness Explanatory Model Interview for a Public Health Survey in Pune, India

Article

Full-text available

Sep 2014
PLOS ONE

Background Mobile electronic devices are replacing paper-based instruments and questionnaires for epidemiological and public health research. The elimination of a data-entry step after an interview is a notable advantage over paper, saving investigator time, decreasing the time lags in managing and analyzing data, and potentially improving the data quality by removing the error-prone data-entry step. Research has not yet provided adequate evidence, however, to substantiate the claim of fewer errors for computerized interviews. Methodology We developed an Android-based illness explanatory interview for influenza vaccine acceptance and tested the instrument in a field study in Pune, India, for feasibility and acceptability. Error rates for tablet and paper were compared with reference to the voice recording of the interview as gold standard to assess discrepancies. We also examined the preference of interviewers for the classical paper-based or the electronic version of the interview and compared the costs of research with both data collection devices. Results In 95 interviews with household respondents, total error rates with paper and tablet devices were nearly the same (2.01% and 1.99% respectively). Most interviewers indicated no preference for a particular device; but those with a preference opted for tablets. The initial investment in tablet-based interviews was higher compared to paper, while the recurring costs per interview were lower with the use of tablets. Conclusion An Android-based tablet version of a complex interview was developed and successfully validated. Advantages were not compromised by increased errors, and field research assistants with a preference preferred the Android device. Use of tablets may be more costly than paper for small samples and less costly for large studies.

Comparing sociocultural features of cholera in three endemic African settings

Article

Full-text available

Sep 2013
BMC MED

Cholera mainly affects developing countries where safe water supply and sanitation infrastructure are often rudimentary. Sub-Saharan Africa is a cholera hotspot. Effective cholera control requires not only a professional assessment, but also consideration of community-based priorities. The present work compares local sociocultural features of endemic cholera in urban and rural sites from three field studies in southeastern Democratic Republic of Congo (SE-DRC), western Kenya and Zanzibar. A vignette-based semistructured interview was used in 2008 in Zanzibar to study sociocultural features of cholera-related illness among 356 men and women from urban and rural communities. Similar cross-sectional surveys were performed in western Kenya (n = 379) and in SE-DRC (n = 360) in 2010. Systematic comparison across all settings considered the following domains: illness identification; perceived seriousness, potential fatality and past household episodes; illness-related experience; meaning; knowledge of prevention; help-seeking behavior; and perceived vulnerability. Cholera is well known in all three settings and is understood to have a significant impact on people's lives. Its social impact was mainly characterized by financial concerns. Problems with unsafe water, sanitation and dirty environments were the most common perceived causes across settings; nonetheless, non-biomedical explanations were widespread in rural areas of SE-DRC and Zanzibar. Safe food and water and vaccines were prioritized for prevention in SE-DRC. Safe water was prioritized in western Kenya along with sanitation and health education. The latter two were also prioritized in Zanzibar. Use of oral rehydration solutions and rehydration was a top priority everywhere; healthcare facilities were universally reported as a primary source of help. Respondents in SE-DRC and Zanzibar reported cholera as affecting almost everybody without differentiating much for gender, age and class. In contrast, in western Kenya, gender differentiation was pronounced, and children and the poor were regarded as most vulnerable to cholera. This comprehensive review identified common and distinctive features of local understandings of cholera. Classical treatment (that is, rehydration) was highlighted as a priority for control in the three African study settings and is likely to be identified in the region beyond. Findings indicate the value of insight from community studies to guide local program planning for cholera control and elimination.

Clinically Applied Anthropology Anthropologists in Health Science Settings: Anthropologists in Health Science Settings

Book

Jan 1982

like other collections of papers related to a single topic, this volume arose out of problem-sharing and problem-solving discussions among some of the authors. The two principal recurring issues were (1) the difficulties in translating anthropo logical knowledge so that our students could use it and (2) the difficulties of bringing existing medical anthropology literature to bear on this task. As we talked to other anthropologists teaching in other parts of the country and in various health-related schools, we recognized that our problems were similar. Similarities in our solutions led the Editors to believe that publication of our teaching experi ences and research relevant to teaching would help others and might begin the process of generating principles leading to a more coherent approach. Our colleagues supported this idea and agreed to contribute. What we agreed to write about was 'Clinically Applied Anthropology'. Much of what we were doing and certainly much of the relevant literature was applied anthropology. And our target group was composed-mostly of clinicians. The utility of the term became apparent after 1979 when another set of anthropologists began to discuss 'ainical Anthropology'. They too recognized the range of novel be haviors available to anthropologists in the health science arena and chose to focus on the clinical use of anthropology. We see this as an important endeavor, but very different from what we are proposing.

Qualitative Analysis of Cultural Formulation Interview: Findings and Implications for Revising the Outline for Cultural Formulation

Article

Jan 2019
Transcult Psychiatr

The DSM-IV Outline for Cultural Formulation (OCF) was a framework for assessment based on principles of cultural psychiatry. The Cultural Formulation Interview (CFI) for DSM-5 provided a tool enabling wider use of cultural formulation in clinical cultural assessment. Validation to justify the inclusion of the CFI in DSM-5 involved quantitative analysis of debriefing interviews of patients and clinicians for feasibility, acceptability and clinical utility. We now further examine qualitative field trial data from the CFI interviews and the debriefing interviews in Pune, India. Administration of the CFI was followed by routine diagnostic assessment of 36 psychiatric outpatients—11 found to have severe mental disorders (SMD) and 25 with common mental disorders (CMD). Domain-wise thematic analyses of the CFI and debriefing interviews identified recurrent themes based on cultural identity, illness explanatory models, stressful and supportive social relationships, and the impact of political, economic, and cultural contexts. A tendency to elaborate accounts, rather than simply name their problem, and more diverse past help-seeking distinguished CMD from SMD groups. Patients valued the CFI more than clinicians did, and most patients did not consider cultural background differences of clinician-patient relationships to be relevant. Qualitative analysis of CFI data and critical analysis of domain mapping of CFI content to the structure of OCF domains indicated the value of revising the dimensional structure of the OCF. A proposed revision (OCF-R) is expected to better facilitate clinical use and research on cultural formulation and use of the CFI.

Explanatory models in psychiatry

Article