Social Organization and Structure: Cultural Contexts Research
The bulk of health-related research in other disciplines has either focused on individuals and their attributes, or on population samples collected through probabilistic sampling procedures. While this approach has a number of strengths, its weaknesses are twofold. First, the cultural context of health problems is all too often ignored by individually centered approaches. Second, people spend a significant portion of their lives within small interactive groups, where their behavior may be impacted as much or more strongly by the group than by any individual characteristic that they bring to the group. Anthropological midrange theory has been highly productive in establishing the importance of cultural contexts and the organization and structure of human systems. These approaches derive from theories of kinship and social network analysis and the impact of cultural structures on human behavior.
Ethnographic network mapping allows applied anthropologists to describe the participants, the behaviors, the kinship and friendship ties, and the consequences of small “bounded groups” in a community. It is accomplished through extensive qualitative interviewing at the community level. In the drug field, the composite ethnographic characteristics of the networks have subsequently been used to create a “drug network” typology or classification system that describes the individual and group context of drug use (such as crack houses, local manufacturing, and distribution). Trotter et al. (1995) and Williams and Johnson (1993) have demonstrated that this type of data is extremely useful for targeting intervention and education activities for the highest risk groups, based on multiple risk criteria. The data can also provide important information about the sub-epidemics that are likely to be part of drug use in network groups (Trotter et al. 1993). In HIV and drug risk prevention, several projects have tested very useful midrange theory to identify network structural elements. These findings provide public health measures of HIV and drug risk conditions (Trotter et al. 1995; Weeks et al. 2001, 2006) as well as epidemiological comparisons of HIV risks within their personal network context in cities around the United States (Williams et al. 1995).
More recently, social network paradigms, combined with community-based participatory principles (CBPR) have provided an important theoretical foundation for understanding infectious disease carriage and transmission through the confluence of Staphylococcus aureus genomics and network analytics. The project has focused on health disparities in Staphylococcus aureus transmission and carriage in a border Region of the United States based on cultural differences in social Relationships (Pearson et al. 2019), providing an example of the potential confluence between biology, social organization, culture, and communication. The epidemiological aspects of genomics are a strong fit with paradigms that include organized social relationships.
Cultural Ecology, Critical Medical Anthropology, and Cultural Epidemiology Theories
The midrange theories related to cultural ecology, critical anthropology, and cultural ecology that have been successfully tested include Barriers to Change research (Environmental Factors Research), Cultural Congruency Models (Conflicts in Belief and Process), Human-Biological Interactions Research, Comparative Cultural Models Research, Deconstructionist Models, Critical Theory approaches, and studies of the political economy of health and illness (cf. Hill 1991; Singer and Baer 1995). These theories have provided a wide range of evidence for the effectiveness of midrange critical theory, cultural ecology, and risk reduction. These range from more theoretical constructions to models for application of the theories (Singer 1995; Singer et al. 2006), and the politics of HIV research (Singer 1994). Cultural disparities-oriented studies have successfully applied these theories to institutional environments impacting social justice issues (cf. Trotter et al. 2019).
In addition, the direct observation of behaviors to determine the impact of the environment on behavior constitutes a primary methodology for health ecological studies. Some of these studies have targeted the results of prevention or behavioral change programs and culturally competent interventions in risk taking behavior. A linked series of studies of needle sharing and needle hygiene practices supported by the National Institute on Drug Abuse exemplifies midrange theory combined with observational methods in a cultural ecological context. The component studies of this project focus on context specific uses of injection equipment among drug users in the United States, as part of HIV risk reduction efforts for drug injectors. Descriptive observations in this realm (Koester 1994; Page 1990; Page et al. 1990) explore both the meaning and the processes of injection drug use, needle sharing, and the public health consequences of drug paraphernalia laws (laws that restrict the possession of syringes that might be used for drug abuse). Later studies (Clatts et al. 1996; Singer et al. 1995) explore the micro-environmental consequences of needle hygiene and needle sharing in depth. One example of the latter approach is the Needle Hygiene Project, conducted by the National Institutes on Drug abuse Cooperative Agreement Program (Needle et al ND, Koester 1994). These studies have led to changes in the recommended messages and training processes for HIV risk reduction among injection drug users.
On a population health level, multidisciplinary teams have also used cultural–ecological models to address risks, and potential prevention activities associated with environmental contaminants. There is considerable interest, and resources available, to identify and mitigate health disparities in underserved populations, and there are a growing number of trans-disciplinary protocols to achieve that goal. (Trotter et al. 2019).
Cross-cultural Applicability Midrange Theory and Methods
One of the most obvious and most practical midrange theories in medical anthropology is the theory of cultural relativity. It is also one of the most miss-applied and politically misused theories in anthropology. This theory is an expression of the empirical findings of anthropologists and other social scientists that groups tend to share consensual world views within the group, and differentiate those world views from others outside the group. Finding examples, from folk medicine to health care prevention programs, is easy, but the findings also frequently result in highly complex actions and recommendations (from calls for cultural competency, to representations that only members of the same culture, or social strata, or language group, or gender, or lifestyle orientation, etc. can understand X culture and therefore can be sufficiently culturally competent to deal with the health and medically related problems of that culture). These forms of cultural particularism tend to reinforce difference at the expense of the possibility for cross-cultural understanding and action. At the same time, the “one size fits all” universalism found in some health interventions is based on a view that constantly stumbles over social and cultural difference, to the detriment of understanding the actual confluence of culture, health, healing and medicine in peoples everyday lives.
One example of a successful applied medical anthropology project in this arena of work is the revision of an international classification of disabilities, the ICIDH CAR2 study. The study had to satisfy 12 data needs in relation to both the ICIDH revision process: (1) identify linguistic equivalencies for conceptual transfer of elements of the classification into local languages and back to English; (2) explore the cultural contexts, practices, and values concerning disablements in the local culture; (3) investigate whether the proposed structure of the classification has good cross-cultural stability; (4) conduct an item-by-item evaluation of the cross-cultural applicability of each facet of the classification; (5) explore alternative models for the classification; (6) collect data on the parity or lack of parity in accommodation and level of stigma between mental health and physical disablements; (7) collect data on the boundaries between the three levels of the: classification system; (8) establish information on the thresholds that apply to disablements (when someone is considered disabled and when are they not shows significant cultural variability); (9) investigate information on stigma attached to various types of disablements; (10) produce a description of