Anja Krumeich

Emerging discourse: Islamic teaching in HIV prevention in Kenya

Islamic values portraying sex outside of marriage as sinful are often believed to contribute to HIV transmission as they reject safe-sex practices. Moreover, stigma associated with sinful behaviour is frequently assumed to interfere with access to care for those infected. In contrast, adherence to religious values such as abstinence is viewed as an explanation for the relatively low incidence of HIV infection in Islamic populations. Inspired by this debate, a study was conducted into the possibilities of using Islamic texts as a starting point for health promotion addressing HIV infection and HIV/AIDS-related stigma in Lamu, a Muslim community in Kenya. The study also explored the potential role of Lamus Islamic leaders in the delivery of that health promotion. In collaboration with Islamic leaders, texts were identified that applied to sexual conduct, health, stigma and the responsibilities of Islamic leaders towards their congregations. In spite of the association of HIV with improper sexual behaviour, Islamic texts offer a starting point for tackling HIV transmission and HIV/AIDS-related stigma. Under particular conditions, the identified Islamic texts may even justify the promotion of safer-sex methods, including condom use.

Why clinicians do not implement integrated treatment for comorbid substance use disorder and posttraumatic stress disorder: a qualitative study

Background Healthcare providers working in addiction facilities do not often implement integrated treatment of comorbid substance use disorder (SUD) and posttraumatic stress disorder (PTSD) while there is empirical evidence to do so. Objective This study aims to get insight into the views of clinicians with regard to the diagnosis and treatment of PTSD in SUD patients. Method A qualitative research method was chosen. Fourteen treatment staff members of different wards of an addiction care facility were interviewed by an independent interviewer. Results Despite acknowledging adverse consequences of trauma exposure on SUD, severe underdiagnosis of PTSD was mentioned and treatment of PTSD during SUD treatment was not supported. Obstacles related to the underestimation of PTSD among SUD patients and to the perceptions of SUD clinicians concerning the treatment of comorbid SUD/PTSD were reported. Conclusions It is concluded that SUD facilities should train their clinicians to enable them to provide for integrated treatment of SUD/PTSD.

Being and feeling like a woman: respectability, responsibility, desirability and safe sex among women of Afro-Surinamese and Dutch Antillean descent in the Netherlands

The objective of this study was to describe and understand gender roles and the relational context of sexual decision‐making and safe sex negotiation among Afro‐Surinamese and Dutch Antillean women in the Netherlands. Twenty‐eight individual in‐depth interviews and eight focus group discussions were conducted. In negotiating safe sex with a partner, women reported encountering ambiguity between being respectable and being responsible. Their independence, autonomy, authority and pride inherent to the matrifocal household give them ample opportunity to negotiate safe sex and power to stand firm in executing their decisions. The need to be respectable burdens negotiation practices, because as respectable, virtuous women there would not be the need to use condoms. Respectable women will only participate in serious monogamous relationships, which are inherently safe. Womens desire to feel like a woman, ‘to tame the macho‐man’ and constrain him into a steady relationship, limits negotiation space because of emotional dependency. Respectability seems to enforce not questioning mens sexual infidelity. In developing STI/HIV prevention programmes this ambiguity due to cultural values related to gender roles should be considered. Raising awareness of power differences and conflicting roles and values may support women in safe‐sex decision‐making.

The scope of prenatal diagnosis for women at increased risk for aneuploidies: views and preferences of professionals and potential users.

The increasing number of prenatal diagnostic tests in prenatal screening strategies, raises the question what tests to offer and why. This qualitative study investigated the views and preferences of professionals and potential users regarding four diagnostic test options for women at increased risk for common aneuploidies. Seven focus group sessions were conducted in The Netherlands between October 2009 and June 2010, with various categories of participants (n = 55): professionals engaged in prenatal testing and potential users of this testing (meaning pregnant women and parents of young children). Participants were invited to mention all pros and cons and their preferences regarding four hypothetical diagnostic test options, presented on vignettes: a standard offer of rapid aneuploidy detection, karyotyping or array comparative genomic hybridization, representing a narrow, traditional and broad test, respectively, and the option of individualised choice. Then, a semi-structured group interview was conducted. The data were analysed by the constant comparative method. Participants identified similar test-specific pros and cons but showed different preferences. Users’ opinion on what test to offer as a general policy differed from what they would choose themselves. All participants agreed that in theory, users should be enabled to make an informed choice about what test to apply, but they disagreed about the feasibility of this ideal. Standard narrow testing was favoured for its limiting effects on emotional and organisational burdens; individualised choice was preferred for assuring women’s decisive influence. The varying opinions reflect different views on what autonomy in the prenatal screening context means, suggest that a single standard test offer is inadequate and that differentiation will be needed.

We are also normal humans, you know? Views and attitudes of juvenile delinquents on antisocial behavior, neurobiology and prevention

This paper presents and discusses the views and attitudes of juvenile delinquents regarding the implications of genomics and neurobiology research findings for the prevention and treatment of antisocial behavior. Scientific developments in these disciplines are considered to be of increasing importance for understanding the causes and the course of antisocial behavior and related mental disorders. High expectations exist with regard to the development of more effective prevention and intervention. Whether this is a desirable development does not only depend on science, but also on the ethical and social implications of potential applications of current and future research findings. As this pilot study points out, juvenile delinquents themselves have rather mixed views on the goals and means of early identification, prevention and treatment. Some welcome the potential support and help that could arise from biologically informed preventive and therapeutic measures. Others, however, reject the very goals of prevention and treatment and express worries concerning the risk of labeling and stigmatization and the possibility of false positives. Furthermore, interventions could aim at equalizing people and taking away socially disapproved capacities they themselves value. Moreover, most juvenile delinquents are hardly convinced that their crime could have been caused by some features of their brain or that a mental disorder has played a role. Instead, they provide social explanations such as living in a deprived neighborhood or having antisocial friends. We suggest that the hopes and expectations as well as the concerns and worries of juvenile delinquents are relevant not only for genomics and neurobiology of antisocial behavior, but also for prevention and intervention measures informed by social scientific and psychological research. The range of patterns of thought of juvenile delinquents is of great heuristic value and may lead to subsequent research that could further enhance our understanding of these patterns.

Health in global context; beyond the social determinants of health?

The rise of the social determinants of health (SDH) discourse on the basis of statistical evidence that correlates ill health to SDH and pictures causal pathways in comprehensive theoretical frameworks led to widespread awareness that health and health disparities are the outcome of complex pathways of interconnecting SDH. In this paper we explore whether and how SDH frameworks can be translated to effectively inform particular national health policies. To this end we identified major challenges for this translation followed by reflections on ways to overcome them. Most important challenges affecting adequate translation of these frameworks into concrete policy and intervention are 1) overcoming the inclination to conceptualize SDH as mere barriers to health behavior to be modified by lifestyle interventions by addressing them as structural factors instead; 2) obtaining sufficient in-depth insight in and evidence for the exact nature of the relationship between SDs and health; 3) to adequately translate the general determinants and pathways into explanations for ill health and limited access to health care in local settings; 4) to develop and implement policies and other interventions that are adjusted to those local circumstances. We conclude that to transform generic SDH models into useful policy tools and to prevent them to transform in SDH themselves, in depth understanding of the unique interplay between local, national and global SDH in a local setting, gathered by ethnographic research, is needed to be able to address structural SD in the local setting and decrease health inequity.

Machismo, public health and sexuality-related stigma in Cartagena.

This paper reports on an ethnographic study in Cartagena, Colombia. Over a seven-month fieldwork period, 35 men and 35 women between 15 and 60 years of age discussed the social context of HIV/AIDS through in-depth interviews, life histories and drawing. Participants considered the transgression of traditional gender roles as prescribed by machismo a major risk factor for HIV infection. In addition, they integrated public-health concepts of risk groups with these long-standing constructions of gender roles and sexuality-related stigma to create the notion of ‘AIDS carriers’. The bricolage between machismo, public health and sexuality-related stigma that participants created and consequent preventive measures (based on an avoidance of sex with people identified as ‘AIDS carriers’) was a dynamic process in which participants were aware that changes in this particular interpretation of risk were necessary to confront the local epidemic.

Reproductive decision-making in the context of mitochondrial DNA disorders: views and experiences of professionals.

Bredenoord AL, Krumeich A, De Vries MC, Dondorp W, De Wert G. Reproductive decision‐making in the context of mitochondrial DNA disorders: views and experiences of professionals.

Multiculturalism and the Construction of Ethnic Identities in Labour and Health Practices: Avoiding the Culturalistic Fallacy in Applied Research

In applied health care research, an essentialised notion of culture is often used when studying ethnic disparities in health and health care access between the majority populations of Western countries and migrants, with ethnic backgrounds that differ from majority population. This notion of culture, however, is considered highly problematic in anthropology and ethnic studies. Therefore, in our research on Dutch illness certification practices, we employed a dynamic conceptualisation of culture. Our research shows that, in practice, when clients fail to meet the implicit norms of this practice, doctors ascribe this nonconformity differently when the client is a migrant than when he or she is a Dutch client. More specifically, when migrants fail to meet the norms, doctors are inclined to automatically ascribe this nonconformity to the assumed cultural background of the client. Consequently, these doctors feel less able to use the tools they normally use to coach their clients. This, in turn, results in more problematic and longer reintegration trajectories for migrants in comparison to Dutch clients in similar circumstances. In other words, framing the problems of migrants in terms of culture results in greater sick leave rates for migrants than for Dutch people. Clearly, culturalistic perspectives on ethnic differences have negative consequences. We therefore implore the application of a dynamic notion of culture in applied research.

Ethnicity in Dutch health research: situating scientific practice

ABSTRACT Objective: A growing body of work is examining the role health research itself plays in the construction of ‘ethnicity.’ We discuss the results of our investigation as to how the political, social, and institutional dynamics of the context in which health research takes place affect the manner in which knowledge about ethnicity and health is produced. Design: Qualitative content analysis of academic publications, interviews with biomedical and health researchers, and participant observation at various conferences and scientific events. Results: We identified four aspects related to the context in which Dutch research takes place that we have found relevant to biomedical and health-research practices. Firstly, the ‘diversity’ and ‘inclusion’ policies of the major funding institution; secondly, the official Dutch national ethnic registration system; a third factor was the size of the Netherlands and the problem of small sample sizes; and lastly, the need for researchers to use meaningful ethnic categories when publishing in English-language journals. Conclusions: Our analysis facilitates the understanding of how specific ethnicities are constructed in this field and provides fruitful insight into the socio-scientific co-production of ethnicity, and specifically into the manner in which common-sense ethnic categories and hierarchies are granted scientific validity through academic publication and, are subsequently, used in clinical guidelines and policy.