‘I just don’t think it’s that natural’: adolescent mothers’ constructions of breastfeeding as deviant

Breastfeeding is recognised globally as the optimal method of infant feeding. For Murphy (1999) its nutritional superiority positions breastfeeding as a moral imperative where mothers who formula-feed are open to charges of maternal deviance and must account for their behaviour. We suggest that this moral superiority of breastfeeding is tenuous for mothers from marginalised contexts and competes with discourses which locate breastfeeding, rather than formula feeding, as maternal deviance. We draw on focus group and interview data from 27 adolescent mothers from socio-economically deprived neighbourhoods in three areas of the UK, and five early years professionals working at a Children’s Centre in the Northeast of England. We argue that breastfeeding is constructed as deviance at three ‘levels’ as (i) a deviation from broad social norms about women’s bodies, (ii) a deviation from local mothering behaviours and (iii) a transgression within micro-level interpersonal and familial relationships. Given this positioning of breastfeeding as deviant, breastfeeding mothers feel obliged to account for their deviance. In making this argument, we extend and rework Murphy’s (1999) framework to encompass diverse experiences of infant feeding. We conclude with reflections on future research directions and potential implications for practice.     

‘Exotic no more’: Tuberculosis,public debt and global health in Berlin

ABSTRACT

Geographical divisions between North and South are coming increasingly undone in the field of global health. Settings in the global North, such as Berlin, are becoming linked up to those in the global South in manifold ways. In this article, I show through discourse analysis and ethnographic research how tuberculosis and its meanings have been transfigured in Western Europe through the worldwide circulation of the disease and its definition as a global health epidemic returning to the North from the South through global migration routes. I then draw attention to the ways in which public health professionals in Berlin make sense of locally implemented economic processes of debt and austerity that have been in effect since the early 2000s. Such processes of indebtedness and privatisation render the strong public health infrastructures that characterise the global North increasingly fragile, and are comparable to the structural adjustment policies that have been imposed upon countries in the global South. I argue that economic processes of austerity in Berlin complement the meaning of TB as an immigrants’ disease, while older meanings of TB as a disease of poverty resurface.     

The development of risk politics in the UK: Thatcher’s ‘Remarkable’ but forgotten ‘Don’t Die of Ignorance’ AIDS campaign

Thirty years on from the dramatic and unprecedented AIDS advertising campaign in the UK organised by the Conservative government of the late 1980s, this article reassesses the experience drawing upon subsequent memoirs and interviews. It does so in the context of an emergence of risk politics in the UK in the 1980s, situated within an historical perspective on the development of risk within modernity. I emphasise the forgotten pragmatic, amoral core of the campaign which challenged the illiberal climate of the times, and how it was possible for a government defined by high moralism to challenge it. I outline the range of pressures that led to the campaign, including the conscious attempt to limit stigmatisation amidst the mood of wartime emergency that prevailed in late 1986/early 1987. Its emergency character meant little direct legacy of harm reduction has endured, but I argue for a wider significance of the campaign as a key moment in the emergence of risk politics in the UK and beyond.     

The Syrian public health and humanitarian crisis: A ‘displacement’ in global governance?

Ongoing failure by the international community to resolve the Syrian conflict has led to destruction of critical infrastructure. This includes the collapse of the Syrian health system, leaving millions of internally displaced persons (IDPs) in urgent need of healthcare services. As the conflict intensifies, IDP populations are suffering from infectious and non-communicable disease risks, poor maternal and child health outcomes, trauma, and mental health issues, while healthcare workers continually exit the country. Healthcare workers who remain face significant challenges, including systematic attacks on healthcare facilities and conditions that severely inhibit healthcare delivery and assistance. Within this conflict-driven public health crisis, the most susceptible population is arguably the IDP. Though the fundamental ‘right to health’ is a recognised international legal principle, its application is inadequate due to limited recognition by the UN Security Council and stymied global governance by the broader international community. These factors have also negatively impacted other vulnerable groups other than IDPs, such as refugees and ethnic minorities, who may or may not be displaced. Hence, this article reviews the current Syrian conflict, assesses challenges with local and global governance for IDPs, and explores potential governance solutions needed to address this health and humanitarian crisis.     

‘What we’ve tried,hasn’t worked’: the politics of assets based public health 1

It is a paradox of recent epidemiology that as material inequalities grow, so the pursuit of non-material explanations for health outcomes proliferates. At one level, a greater recognition of psycho-social factors has deepened the understanding of the societal determinants of health, the links between mental and physical health and the social nature of human need. Too often however, psycho-social factors are abstracted from the material realities of people’s lives and function as an alternative to addressing questions of economic power and privilege and their relationship to the distribution of health. The growing influence of salutogenesis and asset-based approaches is one example of this trend. This paper reflects on the theories of public health that lie behind the discourse of assets, together with some of the reasons for, and consequences of, its popularity and influence, notably in Scotland.     

Collaboration between key populations in a global partnership for health and human rights: Lessons learned from ‘Bridging the Gaps’

Because HIV and AIDS key populations share common social-cultural factors challenging their sexual health and rights (e.g. stigma, criminalisation), there is an assumed benefit of collaborative programmes where various key populations work in solidarity. In this paper, we reflect on how partners collaborated in a complex alliance of over 100 different NGOs, representing and supporting three key populations – lesbian, gay, bisexual and transgender (LGBT) people, sex workers and people who use drugs – working across 16 countries. We used a multiple-method approach of participant observation, qualitative interviews, and a survey to explore the benefits, facilitators and challenges of collaboration. Results show that motivators for collaboration included being part of the larger funding structure with applied impacts, a repressive human rights context, and intersectionality. Barriers for collaboration included identity politics, stigma, and constraints regarding the appropriate timing of new collaborations. Finally, facilitators include practical support for engagement, the framing of human rights in a medical agenda, and recognition of implicit differences. We conclude that for building the capacity for collaboration among socially marginalised groups it is important to develop trust and the ability to recognise strength in difference beyond the initial identification of shared norms and common goals.     

Towards ‘reflexive epidemiology’: Conflation of cisgender male and transgender women sex workers and implications for global understandings of HIV prevalence

ABSTRACT

The HIV epidemic has had a widespread impact on global scientific and cultural discourses related to gender, sexuality, and identity. ‘Male sex workers’ have been identified as a ‘key population’ in the global HIV epidemic; however, there are methodological and conceptual challenges for defining inclusion and exclusion of transgender women within this group. To assess these potential implications, this study employs self-critique and reflection to grapple with the empiric and conceptual implications of shifting understandings of sexuality and gender within the externally re-created etic category of ‘MSM’ and ‘transgender women’ in epidemiologic HIV research. We conducted a sensitivity analysis of our previously published meta-analysis which aimed to identify the scope of peer-reviewed articles assessing HIV prevalence among male sex workers globally between 2004 and 2013. The inclusion of four studies previously excluded due to non-differentiation of cisgender male from transgender women participants (studies from Spain, Thailand, India, and Brazil: 421 total participants) increased the overall estimate of global HIV prevalence among ‘men’ who engage in sex work from 10.5% (95% CI 9.4–11.5%) to 10.8% (95% CI 9.8–11.8%). The combination of social science critique with empiric epidemiologic analysis represents a first step in defining and operationalising ‘reflexive epidemiology’. Grounded in the context of sex work and HIV prevention, this paper highlights the multiplicity of genders and sexualities across a range of social and cultural settings, limitations of existing categories (i.e. ‘MSM’, ‘transgender’), and their global implications for epidemiologic estimates of HIV prevalence.     

‘When we think about risk,we think about rights’: community-based organisations’ staff members' perspectives on risk,resiliency and rights in Juiz de Fora,Brazil

In this article, we draw on a qualitative case study undertaken in 2008 and 2009 of staff working at community-based organisations for at-risk youth in Juiz de Fora, Brazil, to examine staff members' perspectives of adolescent health-risk behaviours and resiliency. We use these data to explore how recent policy changes in Brazil have led to a shift in the ways in which adolescent risk taking is perceived by those working in youth services, and to suggest the influence that this has had on the way in which these entities promote resiliency among the population they serve. Specifically, we argue that Brazil's Child and Adolescent Act of 1990, a policy derived from the United Nations Convention on the Rights of the Child, has been instrumental in reframing for the community-based organisations the question of adolescent health-risk behaviours into a rights-based framework and has shifted the perceptions of those working at such organisations as to who a youth ‘at-risk’ is, why young people engage in risk taking and how best to promote resiliency. This work has implications for understanding both how risk and resiliency are constructed in different social and cultural contexts and how such concepts may change over time due to shifting socio-political climates.     

‘It’s the sense of responsibility that keeps you going’: stories and experiences of participation from rural community health workers in Guatemala

Background

In 1978, the Alma-Ata declaration on primary health care (PHC) recognized that the world’s health issues required more than just hospital-based and physician-centered policies. The declaration called for a paradigm change that would allow governments to provide essential care to their population in a universally acceptable manner. The figure of the community health worker (CHW) remains a central feature of participation within the PHC approach, and being a CHW is still considered to be an important way of participation within the health system.

Methods

This study explores how the values and personal motivation of community health workers influences their experience with this primary health care strategy in in the municipality of Palencia, Guatemala. To do this, we used an ethnographic approach and collected data in January-March of 2009 and 2010 by using participant observation and in-depth interviews.

Results

We found that the CHWs in the municipality had a close working relationship with the mobile health team and with the community, and that their positions allowed them to develop leadership and teamwork skills that may prove useful in other community participation processes. The CHWs are motivated in their work and volunteerism is a key value in Palencia, but there is a lack of infrastructure and growth opportunities.

Conclusion

Attention should be paid to keeping the high levels of commitment and integration within the health team as well as keeping up supervision and economic funds for the program.     

‘A lot of the things we do … people wouldn’t recognise as health promotion’: addressing health inequalities in settings of neighbourhood disadvantage

Health promotion is informed by epidemiology, requires engagement with socially situated subjects and can involve diverging emphases. For some practitioners, health promotion is a specialised set of activities and technical knowledge for disseminating health information. For others, it advances broad-based and interlinked goals of socio-economic and health equality through processes of community engagement and participation. These diverging approaches are explored in qualitative data gathered from health promotion workers and residents involved in an area-based initiative that included aims to reduce health inequalities. The findings describe two distinctive approaches to health promotion that are characterised as ‘procedural’ and ‘cooperative’. Procedural styles, in the manner of ‘top down’ approaches, tend to differentiate between lay communities and professionals, involve predefined channels for community input, rely on ‘off the shelf’ health promotion packages and minimise the significance of local contexts. In contrast, cooperative styles are grounded in empathetic understanding of the impact of socio-economic and other disadvantages on everyday life, enact inclusive community engagement practices and develop ‘bottom up’, locally relevant health promotion initiatives. Noting the limitations of relying only on ‘top down’ or ‘bottom up’ approaches we argue that health promotion in community settings occupies a paradoxical space that is continuously negotiated by both health promotion workers and community residents. Further, health promotion workers need to be able to move between cooperative and procedural approaches in order to navigate the frequently conflicting demands of community, agency and professional expectations in order to achieve the best outcomes for communities.     

From a global crisis to the ‘end of AIDS’: New epidemics of signification

In the past decade, discourses about AIDS have taken a remarkable, and largely unquestioned, turn. Whereas mobilisations for treatment scale-up during the 2000s were premised on perceptions of an ‘epidemic out of control’, we have repeatedly been informed in more recent years that an end to AIDS is immanent. This new discourse and its resulting policies are motivated by post-recession financial pressures, a changing field of global institutions, and shifting health and development priorities. These shifts also reflect a biomedical triumphalism in HIV prevention and treatment, whereby shorter term, privatised, technological, and ‘cost-effective’ interventions are promoted over long-term support for antiretroviral treatment. To explore these changes, we utilise Treichler’s [(1987). How to have theory in an epidemic: Cultural chronicles of AIDS. Durham, NC: Duke University Press] view of AIDS as an ‘epidemic of signification’ to develop a review of ‘End of AIDS’ discourses in recent years. We use this review to investigate the political and philanthropic interests served by efforts to rebrand and re-signify the epidemic. We also hold up these discourses against the realities of treatment access in resource-poor countries, where ‘Ending AIDS’ has not heralded the end of an epidemic per se, but rather the end of external support for treatment programmes, highlighting new difficulties for sustaining treatment in this new era of the epidemic.     

The causes and health effects of the Great Recession: from neoliberalism to ‘healthy de-growth’

In 2008, the world experienced the worst financial crisis since the Great Depression. The crisis is often described in relation to its proximal risk factors such as the proliferation of risky loans and mortgage-based securities, but the root causes of the Great Recession include distal risk factors such as indiscriminate capital flow, excessive financial deregulation, and high concentration of wealth in the top distribution. Ultimately, the crisis is a byproduct of neoliberal policies and the ‘self-correcting market’ ideology that guided national and global macroeconomic reforms since the 1970s. Evidence indicates that the Great Recession led to increases in unemployment and suicides, especially in Europe and in the US. Estimates based on the effects of previous economic downturns suggest that the crisis produced negative health and nutritional outcomes in developing countries. Data, however, also show that recessions can be characterized by increases in life expectancy at birth. These favorable trends seem associated with policy regimes favoring a more egalitarian distribution of income and stronger social protections that can decouple the link between unemployment and suicides during crises (‘healthy de-growth’.). New rules and regulations at the national and global level are needed to prevent future financial crises. The crisis also provides an opportunity to challenge neoliberalism, the ideology of the ‘self-correcting market’ and envision a new model of economic development where GDP growth is longer the main national policy priority. Governments can achieve a regime of ‘healthy de-growth’ if they step in with appropriate policy interventions toward a more egalitarian distribution of income and stronger social protections.     

The trouble with ‘Categories’: Rethinking men who have sex with men,transgender and their equivalents in HIV prevention and health promotion

ABSTRACT

This double Special Issue of Global Public Health presents a collection of articles that seek more adequately to represent sexual and gender diversities and to begin to rethink the relationship to HIV prevention and health promotion – in both the resource rich nations of the global North, as well as in the more resource constrained nations of the global South. Reckoning with the reality that today the global response to HIV has failed to respond to the needs of gay, bisexual and other men who have sex with men, and transgender persons, we turn our attention to processes and practices of categorisation and classification, and the entanglement of the multiple social worlds that constitute our understanding of each of these categories and people within the categories. Jointly, these articles provide critical perspectives on how defining and redefining categories may impact the conceptual frameworks and empirical evidence that inform global understandings of HIV infection, those communities most vulnerable, and our collective response to the evolving HIV epidemic.     

I think I can’t,I think I can’t: associations between parental pessimism,child affect and children’s well‐being

The present study was designed to examine the relations between parental pessimism and peer relations and health in preschool children and to examine the role that child positive and negative affect played within this relationship. Thirty‐seven mothers and their children (mean age = 48.1 months) volunteered from local preschools and daycares within a mid‐sized Atlantic Canadian city. Mothers completed the Generalized Expectancy for Success Scale—Revised, as well as the Positive and Negative Affect Schedule and a brief demographic questionnaire. Teachers completed the Preschool Play Behaviour Scale. Results revealed significant correlations between parental pessimism and child affectivity and social play, and between child affectivity and various types of play behavior. Significant interactions were also found between parental pessimism and child affectivity in the prediction of social play behavior. Results are discussed in terms of the importance of parental attitudes to a child’s social and physical well‐being.     

‘I don’t think it’s risky,but…’: pregnant women’s risk perceptions of maternal drinking and smoking

In Switzerland, official recommendations relating to alcohol and tobacco use during pregnancy are based on a zero-tolerance policy. However, epidemiological research indicates that some pregnant women do not adhere to the abstinence principle, and this raises the issue of how pregnant women identify and respond to health risks. This article draws on a sociocultural study of 50 mainly white, partnered and educated pregnant women carried out in Switzerland between May 2008 and June 2009. The study used semi-structured interviews that examined how and in what ways pregnancy had changed women’s consumption of alcohol and tobacco and their perceptions of their riskiness. In this article we draw on these data to examine participants’ perceptions of the risks of smoking and drinking during pregnancy. We examine three main issues: women’s understandings of official recommendations, their contextualisation of risk in daily life and the moral issues which they saw surrounding smoking and drinking during pregnancy. We found that the women in our study perceived drinking and smoking during pregnancy as different types of risks with different meanings. The participants contextualised official recommendations about drinking during pregnancy and had their own views about its riskiness. In contrast all participants saw smoking as harmful and risky irrespective of the level of consumption. The pregnant women in our study saw smoking during pregnancy as a risk-taking behaviour and a failure to act in the best interest of the foetus. In contrast, under certain conditions, they saw moderate drinking of alcohol during pregnancy as acceptable and responsible behaviour.