Structural Key Terms

Gender as a social institution (could refer to Connell

-Gender-based power imbalances are not merely an interpersonal and behavioral problem, but rather one that also exists in the collective and structural realms. - Infidelity as the product of social organization, not personal failings - Gender as globally and locally constituted Connell first developed the concept that gender is a large-scale social structure rather than a matter of personal identity (i.e. it is a property of societies, not individuals). The family, the state, and the street are all gendered institutions and each of these institutions are characterized by a particular social organization of gender, which can be identified as a 'gender regime'. It is important to note that gender, if defined as a social institution, can be viewed as a structure which constrains one's agency but does not ultimately determine practice. Horton and Dworkin's paper on HIV prevention argues that disparate rates of HIV among men and women are influenced by gender norms (female passivity, male virility) that are created by the social organization of gender. They stress the importance of prevention programs and social policies that make structural changes which, in turn, challenge damaging gender norms and gender power imbalances as a means of reducing HIV risk. -Connell was quoted in Lecture 3: Gender Reference: Haitian gender dynamics: sex becomes a commodity b/c of what is expected -de Zalduondo, B and Bernard, JM. (1995). Meanings and Consequences of Sexual-Economic exchange: Gender, poverty and sexual risk behavior in urban Haiti. Conceiving Sexuality: Approaches to Sex Research in a Postmodern World (New York: Routledge) pp 157-182.

Sex worker

A sex worker is an individual who participates in the sex industry by performing or providing sexual acts in exchange for compensation. This compensation is not always monetary; sex workers may perform for other commodities, including status, physical goods, or xxxxx. Harm reduction techniques have been applied to sex workers and within the sex industry to protect the health of both sex workers and their clients. Structural interventions to reduce harm include compulsory condom use and compliance monitoring, and the decriminalization of sex work. Under umbrella of sex industry Have sex for something; doesn't have to be monies Escorts; visibility → brothel has different vulnerabilities than escorts; street workers, people with intermediaries (pimps/madams); need to understand complexities and differences in order to implement effective structural intervention. not the most necessary by if need words Example: Lectures: Lecture 9 - HIV and Sex Work

Gender norms/ideals

A shared cultural idea about the 'natural' means of being. There is a 'should' contained within the norm. Because these are 'ideals' they are often impossible to live up to but can affect how individuals respond to interventions and what they prioritize (not always health). The idea that 'real' men do not seek medical care could be viewed as a barrier to providing preventive medicine like colonoscopy screening. -Hegemony: gender/norms and ideals can be dictated through hegemonic ideals; for example: In a patriarchal society, men are in control and women are to be subservient Lecture 3: Gender (Norms based on Sexual geography) Hirsch et al. (2009). The Secret: Introduction; Chapters 2-4 Dominican MSM who play up norm of masculinity. Lecture 3 (Gender): Reading: Horton and Dworking: disparate rates of HIV influenced by gender norms. Consider: Masculitinies; femininities

Framing

A way of articulating constructs of social problems that require different solutions, allocating responsibility (who is the barrier to the solution, causing the problem); assigns domain in where you would solve the problem (defines terrain of action), not just technical engagement but galvanizes How we frame our issues may bring attention to and relevancy to stakeholders, a way to leverage information towards end goal. Has to be convincing to people, can't challenge existing structures of power. ● Ex: Gun rights/violence - protection of rights & safety vs. (public health) threat to safety of children Framing is a broader concept of causal theory. ● Ex: Automobiles —> obesity —> built environment —> infrastructure solutions Related to the notion of Causal Theories - points finger at who is responsible ● Soda in schools - not the only reason for childhood obesity, but getting soda out of schools has a clear culprit ● Workplace accidents - employers need to be held responsible, something that is preventable rather than an accident (Triangle Shirtwaist Factory Fire) Anti-bullying: ● Make it an issue that everyone cares about ● Framed as health issue vs. political issue (safer political territory) ● Analysis applicable in many ways, not just bullying Other examples: ● MSM in young black African Americans, rise of HIV/AIDS - not just something the health department can solve, multi-sectoral response is needed, issues must be framed outside the stakeholders of health because they are also responsible for producing this vulnerability ● Food justice - include people who produce the food you eat, creating coalition through shared understanding of problem at hand ● Sex work - Durbar; no longer moral problem, but a worker's rights issue ● Mass incarceration - to bring economic conservatives on board by appealing to cost savings (releasing elderly who are probably no longer a threat to society) ● Smoking - over the course of tobacco epidemic, individual choice —> industry's fault ● Michelle Obama's Let's Move initiative - creates set of targets, allies, distracts us from other potential causes (not taking on food industry), points us to a set of solution to problems Dorfman et al: ● Policy framing is most effective when it appeals to widely held values or speaks to a moral issue. ● It is therefore important to keep in mind the cultural and national values of the population you are attempting to motivate with your framing techniques. ● The media, particularly the news, can be used to help frame issues to the larger population, but news stories are often framed episodically, hiding the larger context that is a necessary part of understanding effective health policies. Different ways of explaining the same thingà Oppression Paradigm: sex work is an expression of patriarchal gender relations and exploitation and violence against women are intrinsic to sex work. Sex work as inherently oppressive. Empowerment Paradigm: sexual commerce is work, involves human agency, and may be potentially empowering for workers.

Agency

Agency is a difficult concept to define, because of its similarity to free will. Agency, then, cannot be proven and is therefore best characterized by its limits in overcoming structure. Schafer, Ferraro, and Mustillo write that "agency is circumscribed to the extent that people's wishes, goals, or expectations are thwarted" (2011). Individual agency may be limited by the constraints imposed by structural factors in a person's environment. Restricted by structure: gender as a structure which constrains but does not determine practice The male dominican sex workers exercised agency when they made the economic deicision to create and embody personas that they felt would be attractive to sexual tourists. "In order to produce a marketable fantasy, local men had cultivated the ability to deploy their masculinity and sexuality in ways that maximized their desirability to tourists. As an expression of this, men's sexual narratives often emphasized how Dominican men's sexualities and bodies are fundamentally ''different'' from those of their (mostly white and foreign) clients. These narratives exaggerated the differences between themselves and the gay foreign clients they served, claiming that Dominican men's bodies were ''stronger,'' more masculine, or more capable of physical endurance than the ''weaker'' bodies of the foreigners who visited their country. ''Many gringos don't have bodies like us—stronger, hotter,'' Padilla, M. B. (2008). The embodiment of tourism among bisexually-behaving Dominican male sex workers. Archives of sexual behavior, 37(5), 783-793. Session 9: HIV and Sex Work

Blankenship framework for structural interventions

Blankenship, Bray, and Merson described a framework for classifying structural interventions that identified three major contextual factors that they acted upon: availability, acceptability, and accessibility (2000). Each of these can target the individual, organizations, or the environment. Availability refers to rules and regulations that attempt to change the incentives for people in the healthier direction. Interventions that affect availability include: making harmful drugs illegal, speed limits, seat belt laws, taxing tobacco and alcohol, etc. Interventions that affect acceptability, try to change the social norms that influence behavior. Examples of such an intervention are smoking campaigns that try to dispel smoking as cool and instead try to make it cool to make choices that maximize health. On the other hand, shame can be used to make individuals or organizations behave in healthier ways. Finally, accessibility interventions try to provide all people with equal resources, power, and access to healthy options. An example could be universal healthcare or giving away bicycle helmets or car seats. Lecture 2: What are Structural Approaches? Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural interventions in public health. Aids, 14, S11-S21.

Community-led structural intervention (CLSI)

CLSI are more sustainable and effective than interventions implemented from outside sources due to the element of ownership and empowerment ○ Allow community to determine needs of the community ● Community ownership and community empowerment are key factors for success of intervention ● CLSIs are community-level interventions that mobilize communities to identify and intervene upon structural factors driving vulnerability to disease(Sommer & Parker, 2013, chp 10). They encompass different participatory approaches in public health such as community organizing, community development, and capacity building to empower the community about a certain issue. ● Inherently ecological and emphasize interplay between structure and agency (Sommer and Parker, 2013, chp 10). ● Reshapes opportunity structures through structural interventions while building individual and community agency through empowerment process ● This includes "social interventions" such as shaping interpersonal norms and behaviors, targeted through organization policies in setting where risk is produced and reflect on what exactly are the community priorities. ● Targets more distal/structural factors that drive vulnerability of disease and social issues (Sommer & Parker, 2013). EX: Sonagachi project in Kolkata, India: o First ever sex worker organization that came into being in India in 1992 as a result of large scale public health intervention among the brothel based sex workers in the Sonagachi red light district o The organization later owned and now is running the largest HIV intervention program in the country. o During the scaling up process, the community shifted the responsibility from a biomedical intervention to a community-led structural intervention by taking ownership of the issue o Now known as Durbar, the Sonagachi Project stemmed into other structural interventions such as microfinance, etc for the community Citation: Sommer, M. and Parker, R.G. 2013. Structural Approaches in Public Health. 2013. New York: Routledge University Press.

Causal narratives/causal theory

Causal narratives or theories in the public sphere trace processes from the cause of a public problem to the outcome. Stone highlights that causal narratives are formed in the public fear through "image making where images have to do with fundamentally with attributing cause, blame, and responsibility" (1989). In this vein, problems do not become problems in the public sphere simply by their existence. It takes political actors with influence or power to deliberately portray problems in a way that helps them win people over to support them. Therefore, although causal theories are often delivered as fact, they are not neutral. there is always someone to blame and to hold responsible. In this way, causal narratives are crucial in setting defining public health problems and setting policy agendas. Different stakeholders are constantly proposing different causal theories that would entail separate agendas and solutions. However, causal narratives aren't automatically placed on the policy agenda. There has to be a notion that things could be different, that current process isn't inevitable. · What do they do o (1) challenge or protect existing social order o (2) assign responsibility so that someone will have to stop an activity, do it differently, compensate victims, or face punishment o (3) legitimate and empower new actors as 'fixers' o (4) create new political alliances among groups o Not about what is true or what is the ultimate cause of harms; rather, about assigning blame and moral responsibility · "problem definition is the active manipulation of images by competing political actors" · What is the role of science and the law? · Elements for success with causal theory o Visibility; access to the media; allies in prominent positions o the theory accords with widespread and deeply held cultural values; reflects national mood (e.g., shift to a market economy and emergence of vulnerability to HIV) o implicit prescription entails no radical redistribution of wealth or power (hah! This is our challenge) o How is this notion of causal theories relevant to the concept of structural interventions? o How does the notion of causal theory connect to prior discussion of frames? · Obama—lets move campaign o Causal theory: kids not exercising enough o Establishes targets and potential allies o Delineates position in way that may disagree or not o Who will you bring to the table, o Causal theory as under umbrella of framing ex. School based nutrition → Soda access in school. ex. Factory workers → Shirtwaist Factory Fire

Gendered opportunity structures

Certain institutions that have a dominant gendered structure (police as male). Part of the institution may encourage this image and keep that institution gendered in this way. The family and the state (army and policy) as gendered institutions. These institutions often reproduce the structure that enforces their status (Bourdieu; hegemony). Gendered opportunity structures are institutions through which people navigate as they build their lives, but they are inherently unequal. Education, labor market, marriage are all examples of this. The allocation of opportunities are not equal which recreates inequalities. ● Like racial inequality as a social institution: this is not a physical institution, it is an enduring social structure that exists outside of people. Gendered opportunity structures ● We spoke about gendered extramarital opportunity structures (The Secret). ○ In some social contexts, women do not have the ability to interact with males other than their husband, whereas men may be encouraged to be seen with multiple other partners so as to bolster their social capital. In some cases, men are supposed to socialize with other men, but women do not have this opportunity. While the event is supposedly about conversation, it often turns into sex. ● Even within higher education, women generally earn less than men. This reflects the gendered labor market. ● Opportunity structure: the allocation of opportunities/resources differentially that fosters and promotes inequality. Potential structural interventions addressing gender institution: ● Gender based violence campaign This relates to structural interventions because it is important to think about the opportunities that people have that might put them at increased risk or encourage certain behaviors that can be detrimental to their health. Socially organized, cross-culturally and historically variable ways in which opportunities to acquire valued resources are differentially allocated to men and women (and other genders) -what about feminization of aids? Women being used? Anything to do with opportunity? Is this what essentialism is? -Extramarital opportunity structures: - Labor related migration and mobility - The gendered organization of family life - Men's peer networks and forms of socializing Lecture 3: Gender

Farley's definition of structural - physical, media, social, accessibility

Consumer products that have an effect on health Limited = reduces use; Widespread = increases use Quantity, prominence, price EX: tobacco, alcohol, guns, condoms...etc Physical Structures Fixed in environment, characteristics of produce Influence behavior by: creating/inhibiting opportunities (gun-safety locks, sidewalks), sending messages about rules of behavior, Big and small physical structures (sidewalks vs. Motrin bottle/cap) Social Structures Laws, policies, and social rules that regulate individual and interpersonal behavior (indoor smoking bans, seat belt laws) Organizations in society that influence behavior indirectly (schools, jobs, recreation programs) Media Messages Messages in mass media: tv, radio, magazines, newspapers, internet Send messages/communicates to people about behavioral norms and values, framing events Farley's definition of structural interventions encompasses four main points. **Grand Rounds Video-in class** **Lecture: Structural Approaches (week 1)**

Compulsory heterosexuality

Elements of social organization that make heterosexuality appear to be the default, morally superior default practice. Class examples: Nosy relatives' questions "do you have a girlfriend, little Bobby?" Prom. Wedding figures. The material universe in which we live. Marriage laws. ● Manifestation of underlying moral hierarchy; consider laws and practices that reproduce that inequality sexual inequality forcing people in the closet Uganda • Elements of social organization that make heterosexuality appear to be the morally superior default practice: - Prom - Wedding figures - Marriage laws - Nosy relatives' questions • Lived experience of sexual inequality Lecture 4: Sexuality Readings: Hatzenbeuhler et al Bullying and anti-LGB: negative health outcome from stress model

Discrimination

Discrimination is the active process in which groups of people marginalize the others. It is an unjust or prejudicial treatment of different categories of people and things, especially based on factors like race, gender, sex and educational level. It is similar to stigma in the sense that it is a behavioral reflection of stigma. -stigma towards convicts and then discriminatory practices of not hiring them more active processes -parker and aggleton paper to find the relationship between stigma and discrimination -acting out of stigma that results in unequal or unfair treatment of those strimgatized groups -cant write about the [chip]munks ● Discrimination is an action, a verb; Stigma is a process, a noun ● discrimination intervention would change what you can and cannot do--hiring practices, zoning // stigma intervention would change people's hearts--increased representation in media, teaching about diversity EX: Housing laws preventing African Americans from securing apartments, red lining, South Africa apartheid Yang: Discrimination of not counting schizophrenics bc they are stigmatized as less than human.

Harm reduction

Does not require abstinence, but works to limit the harm that occurs through the practice. It aims to address the "adverse health, social and economic impact of drug use without requiring abstinence from drugs." [1] - Common HR interventions for injection drug users are education about injection risks, needle and syringe exchange, opioid substitution. [1] - Scale up often interpreted as (1) reaching larger numbers of people in a given place, (2) coverage of larger geographical area, (3) increasing scope and services offered, (4) reaching high-risk groups such as sex workers and prisoners. [1] - Primary goal is reduction of drug-related harm, not drug use per se - 2 Key factors important for successful implementation: government support and multisectoral involvement. o In China, HR caused massive turn-around in thinking from the government (esp law enforcement agencies) which required communication and cooperation between agencies: between the Ministries of Health, Public Security, and Justice, and the Food and Drug Administration. [2] - Opponents to Harm Reduction usually have a moral objection, and that abstinence should be stressed over harm reduction [1] Tkatchenko-Schmidt, E., Renton, A., Gevorgyan, R., Davydenko, L., & Atun, R. (2008). Prevention of HIV/AIDS among injecting drug users in Russia: opportunities and barriers to scaling-up of harm reduction programmes. Health Policy, 85(2), 162-171. [2] Sullivan, S. G., & Wu, Z. (2007). Rapid scale up of harm reduction in China. International Journal of Drug Policy, 18(2), 118-128.

2. Relationship between theory and intervention JJ (Anything with Blankenship?) Interventions are not about picking the "right" theory.

Effective interventions often start with sound theory. Theory is simply the explanatory narratives and ways of understand that emerge from analyzing the world around us. Well planned interventions are based on such a theoretical understanding of the world (that could/should also be supported empirically). Interventions identify practical and effective opportunities to intervene within these theories of how health outcomes are produced. Interventions not grounded in theory are unclear about where to focus their efforts and have trouble interpreting the eventual results of the intervention. Ex: Minority Stress Model as a theory supporting anti-bullying initiatives. Harm reduction supporting needle exchange programs or sex worker initiatives. Lecture 2: What are Structural Approaches Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural interventions in public health. Aids, 14, S11-S21.

Cultural activism

Harnessing influential individuals and institutions within a society to promote change. Cultural activism often synthesizes art and activism in order to promote social and political change. For example, Pete Seeger's music conveyed messages that people could easily relate to and rally around. ● Structural Interventions for HIV and AIDS ○ Community Mobilization: rallying people behind a message. ○ Grabbing people from the moral high ground to associate with the stigmatized (Monks in Thailand). ■ Eating the food prepared by HIV positive people ● Cultural activism by powerful social institution (religion) ○ Looking at the religious tradition to see what can be used to mobilize people ○ Find important/influential leaders to mobilize Lecture 3: Gender

Cultural competence as a response to racial (or ethnic) disparities

In an article, Richard Parker proposes that if society became more culturally competent, we may see a decrease in discrimination that stems in the perceived "other-ness" of minority groups. Cultural competence, or the awareness and understanding that individuals of diverse backgrounds can coexist, could be addressed through increased positive representation of gender or racial minorities in mass media, or school curricula and legislation that is inclusive of sexual minorities, for example. Another example lies in radio campaigns from Mexico which worked to sensitize listeners by presenting dialogue that destigmatized being gay or having HIV. Reading: Hatzenbeuler - teaching diversity through increased reprisentation

The political economy of sexuality

History of usa importing migrant labor · Sexual practices of migrants in the US given that they are disenfranchised here ● Political economy referes to the resulting xxxxxxx when economic and polictical sytems intersect. The same systems can then have very different expressions on cultures, depending on how they intersect. The implications of political economy limits or defines the types of structural interventions that are possible in a given setting. Political economy is a framework for understanding context that is more specific. More than culture, ideology and belief--you have to look at systems of power. Political economy also takes into account how power is organized. That's Political economy. [Whatever is not explained by culture is explained by power; that is what political economy refers to.] Example: Loomis et al. (2009) on Political Economy and of Fatal Occupational Injury. [States were grouped into "political economic ranges" or Categorization of states based on Balance of power between labor and capital (strengths of unions - % unionized workforce, rate of grievances, presence of right to work laws, % unemployed)] • Find that higher fatal injury rates associated with: • Low union density, low labor grievance rates, low social wages, high unemployment, right to work laws • Demonstrates the relative power of labor and the role of the state in creating work environments and health For example, we can look to the ways Vietnam and Cuba are both "socialist" countries, but politics shape the specifics of economic organization. ● example: Bloomberg v deBlasio's NY libraries. The renovation of the main branch of the New York Public LIbrary, a Bloomberg initiative, has been halted; funds will likely be redirected to renovating local branch libraries, a deBlasio initiative. ● example: occupational safety and health. being in RightToWork state (hard to form union) = higher rates of injury ● example: Paul Farmer's dam → rich people get energy → poor people get...AIDS? ● example: The oil and car industries dominate the way we build infrastucture → which leads to less walkable/bikeable cities, car culture and obesity. ● example: US v UK. who is the big loser in a single payer systems? insurance companies. so like...campaign financing schemes, cultural elements like a fear of big government. Lecture 6: Economic organization & production of health inequalities Nowatzki, N. R. (2012). Wealth inequality and health: a political economy perspective. International Journal of Health Services, 42(3), 403-424 Loomis, Dana, Michael D. Schulman, A. John Bailer, Kevin Stainback, Matthew Wheeler, David B. Richardson, and Stephen W. Marshall. (2009). Political Economy of US States and Rates of Fatal Occupational Injury. American Journal of Public Health. 99(8) [this is useful as an example of what political economy means in a very concrete way]

Income vs. wealth

Income refers to what someone earns or receives through gifts, government assistance, or returns on investments; wealth is what someone owns, including assets and inherited family worth. Wealth inequality is said to be a stronger predictor of health outcomes than income inequality as it tends to be more stable, though wealth is often difficult to define and measure. Though it is more reliable, wealth is not always protective. This also leads us to recognize that economic inequality is similar to racial inequality in that differentials between the shorter and longer end of the stick affect health outcomes. EX 1) Early studies on the economy and health focused a lot on income, but didn't show very reliable results. Nowatzki's focus on wealth inequality rather than income inequality shows a more significant relationship with poor population health. She makes the crucial point that the unequal distribution of wealth is closely tied to the political power and health-promoting resources associated with wealth (relating back to structural aspects of racial inequality), supporting the argument that a focus in income inequality may seriously underestimate the health effects of inequality. However, wealth remains difficult to measure comparably, especially across countries. EX 2) Important to recall that wealth is not always protective: example from class was a study by Piot examining HIV and wealth in a number of African countries. It showed that the wealthiest quintiles actually had higher rates of HIV in many countries, for both males and females. EX 2a) Study by WHO showed relationship between level of country development and obesity, showing that the more developed you are greater your ratio of overweight to underweight income as yearly salary and wealth more difficult to measure; different health outcome dependent on wealth; influence of families wealth; income interventions do not attack root causes Lecture 5: Economic Organization Nowatzki, N. R. (2012). Wealth inequality and health: a political economy perspective. International Journal of Health Services, 42(3), 403-424.

16. Cultural Construction of Sexuality (Defined on Rubric by Hirsch)

Locally meaningful categories of people's identities ● Involves identity, partners, behaviors, and use of space (car/truck example from class) ● Also influence of religion of what sexuality means to people Another way to think about it: cross culturally set of variables and meanings given to practices, partnerships, identities An idea that things are shaped to mean different things in different places Who is thought to be an appropriate sexual partner? Late 80's, early 90's, totally revolutionary concept that de-centered essentialism. Limits: doesn't help us understand how sexuality changes, or include questions of power and inequality Can open the door to what's in people's minds, but does not help us think about constraints. Moral evaluation Ex: Anal sex in Delgollado / thong underwear (but not enough to help us understand, must go beyond) -worldwide diffusion of companionate marital ideals that emphasize social and emotional intimacy - if first sexual encounter is with a sheep, perhaps setting up boys to seperate feelings from sex acts

Meso-level interventions

Meso-level interventions are those that are in between big structure and individual approaches. It is a middle level intervention, it links things in the system. For example, a clean water intervention is not eradicating global capitalism. We can argue that what is at the meso level, it can be used as a conceptual tool of thinking beyond the individual, but without having to overturn the whole structure of inequality in the world. ● A meso-level intervention addresses something that is changeable, something that could be transformed through collective action. It is a way of thinking structurally that doesn't force you to overthrow global capitalism. ● An example of this can be stop-and frisk, and how it relates to stress. A meso-level intervention would be the media coverage of the issue, community oriented activism, and the framing of it as a problem. ● Hirsh article: ○ Meso denotes institutions, ideologies, or social processes that are: ■ Neither at the micro, individual, or interpersonal level (such as beliefs or characteristics of interactions) nor at the macro-social level (such as socially-structured inequalities of race, gender, sexuality) ■ Characterized by a sociologically-plausible or empirically described causal relationship to a health-relevant practice ■ Conceivably modifiable through sustained strategically organized collective action ■ EX: pushing for better working/liiving conditions of migrant workers to reduce HIV risk/vulnerability Lecture 5: Economic Organization Hirsch, Jennifer S. 2014. Labor migration, externalities and ethics: Theorizing the meso-level determinants of HIV vulnerability. Social Science and Medicine. 100: 38-45

Contributions of civil society to structural interventions

Often evidence and statistics are not what cause policy; it is often through collective agency of civil society to change/alter structures. · Ways in which collective action can alter structure. · Civil society has a role in structural interventions because they can advocate politically for policy change. [Understanding interactions between policy and community members]. There can be direct political advocacy, but also cultural activism and the way the problem is framed. Civil society plays an important role in pushing the envelope and demanding certain policy changes. An example of this can be seen with the Dream Act and how the Dreamers came out and said that they should be considered citizens and should have all of the rights that a citizen does. Civil society works collectively to transform the social conditions that create health. Other examples are Sonagachi/Durbar in India or ACT UP [group of gay men, AIDS activists who got FDA to...] in the United States. examples: community mobilization; Richard Parker's HIV/AIDS Brazil [examples: Thai monks destigmatize HIV by letting infected people cook food] Examples: In Lecture 9: HIV & Sex Work, we discussed a former sex worker's efforts to build Unions/rights for sex workers in Brazil.

Social Risk

People engage in practices potentially detrimental to their health in order to secure valued (at least by them) social goals "What social good is achieved through: motorcycle riding? skydiving? unprotected sex? bingedrinking? Social transaction. People refrain from engaging in practices potentially beneficial to their health to avoid losing valued social resources: they may Avoid learning HIV status, don't seek medical care, Don't use condoms, Ride motorcycles, ski or bicycle without helmets - "meso-level" concept -Social risk can structure what is perceived as sexual risk. Rather than the main concern being avoiding infection, engaging in safe sex instead involves choosing the right extramarital partners who won't risk damaging your public image. - PH initially disseminated the lie that if you are with one partner you would be safe-->no longer true for women References: **Lecture 3: Gender** Readings: Hirsch et al. (2009). The Secret: Introduction; Chapters 2-4, Conclusion

Political economy

Political economy refers to how economics shape politics in culture. It describes how politics works in an economic context, and the interrelationship between economic and political power institutions. The concept helps us understand how the society goes beyond the local and social level. Analytic approach that takes into account the organization and relationship between politics and economy; context for discussing power. EX: · Shaped by capitalism · EX: Communist Vietnam manufactured goods · Cuba still had Communism but more ownership of products take into account politcal and economic organization; risk factors; diabetes tied to inequalitites of lack of care; food deserts; access to parks; analytic approach that takes into account the organization of (and relationship between) political and economic power both cuab and Vietnam are socialist countries but Vietnams flavor of socialism and market order and cubas is state ownership of shitàeconomies different because of the politics àarticle about occupational safety in health being in right to work stateàhigher rates of injury àpolitical economy shapes possible intervention why is USA does pol econ get in way of single payeràinsurance providers not into i àway about talking about context; need to look at systems of power àdam built by world bank · Puts an emphasis on how political power shapes the organization of production (rather than distribution, exchange, or consumption) · Takes into account history in general and economic history in particular · Can be at a local, state, national, or other perspective Lecture 5: Economic Organization

Difference between risk and vulnerability

Risk provokes the potential for blame and focuses on the choices that individual people make, thus risk leads you on the path to a more individual oriented analysis whereas vulnerability leads to a more population level approach and intervention and the social vulnerabilities (for example vulnerable populations) that people experience. Structure relates to vulnerability because various structures can increase the risk of socially vulnerable groups, and thus put people in a place where there is the potential for harm. An example of this when sex work is criminalized and not considered a legitimate profession. Women are thus vulnerable to assaults from clients, unable to demand better working conditions, etc. because their job is illegal. Thus they are at increased risk for sexual violence and HIV. Migrant laborers are another vulnerable population in terms of their risk of HIV/AIDS (their living situations, distance from partners, lack of any other forms of pleasure). A critique of vulnerability is that it represents people as too abject and unable to help themselves and can potentially take away their agency to protect themselves in a vulnerable environment/community. Lecture 3: Gender -Refer to risk/vulnerability from migrant work in U.S. by Mexican workers; refer to how framing a problem a certain way changes the perspective/definition→ Lecture 8: Framing** Reading: Hirsch et al. (2009). The Secret: Introduction; Chapters 2-4, Conclusion

Sexual Geographies

Sexual geography is a field of study within geography that encompasses relationship and interactions between human sexuality, space and place and themes studied in, but not limited to cultural geography. -meso-level concept • Spaces have sexual meanings • Spaces SHAPE AND ORGANIZE sexual practices - Bathhouses (stuff happening here may be less likely to happen at the grocery store) (Chapter 16 of The Secret) - The three stages of marital sex (logic of joke is that places have sexual valence.), Mile-high club, Table-dance joints (The hustler club, all along cross-bronx expressway) • Space an important element to consider in terms of the structures that shape sexuality ● space for the production and performance of sexuality. manifests inequalities, changes over time ● Understanding how spaces work can be crucial to designing effective interventions influenced by gender norma Lecture 3: Gender Readings: Hirsch et al. (2009). The Secret: Introduction; Chapters 16

Sexual Rights

Sexual rights refers to the rights of individuals to not be discriminated against on the basis of their sexuality. Sexual rights are diverse with many themes such as the right to an abortion, effective treatment of STIs, and sexual identity [1]. Examples of sexual rights are: the right to not be discriminated against; right mean obligation of the state to be non-discriminatory; right to sex that is comfortable and without risk; right to experience sexuality in a way that doesn't incur health risks. Sexual rights have been generally fortified largely from the ground up, through collective action. In context of Brazil, was seen as largely an outgrowth of HIV advocacy work. Fighting against the discrimination of people with HIV implied a basic criticism of stigma related to gay men, transvestites, and sex workers, populations especially vulnerable to HIV. It helped to build the platform for sexual rights advocacy of the early 2000s [1]. HIV interventions: Community development and promotion of sexual rights replacing traditional models based on information and skills building [2] Sexual identity is not just an individual experience but has broader societal implication due to social construction of various stigmas associated with what it means to have various sexual identities. Intersects various structures: religion (abortion); gender (differences in sexual rights and privileges), If "Compulsory heterosexuality" is not one of the other terms you are defining for the exam, it could be tied into this one

Minority stress model

Stigma, prejudice, and discrimination create stressful environments that can lead to mental health problems in people who belong to stigmatized minority groups. All people experience stress, but identity and affiliation with certain stigmatized populations increases stress, which can lead to long-term consequences. This model demonstrates that while stigma is very much a social construction, it can have result in physical manifestations of illness. There are 3 processes of minority stress: 1) External stressful events 2) Expectation of such events 3) Internalization of negative attitudes Underlying assumptions of minority stress model: 1) minority stress is unique and additive to other stressors experienced also by the majority, such that minorities experiences more stress; 2) minority stress is chronic and due to relatively stable social structures; and 3) minority stress is socially biased ("it stems from social processes, institutions, and structures beyond the individual rather than individual events or conditions that characterize general stressors or biological, genetic, or other nonsocial characteristics of the person or the group") [1] [1] Meyer, I. H. (2003). Prejudice, social stress, and mental health in lesbian, gay, and bisexual populations: conceptual issues and research evidence. Psychological bulletin, 129(5), 674.

Structural interventions to address sex work

Structural interventions to address sex work go beyond individualized approaches like condom promotion or education programs about HIV risk. Empowerment is a key part of these interventions, as evidenced by the Sonagachi Project in India (Swendeman and Jana), a community-led structural intervention that established a sex workers cooperative that promoted financial security/autonomy (in the form of loans) and gave sex workers the ability to negotiate with governmental officials. This empowerment is thought to have led to higher rates of condom use and lower rates of HIV among sex workers. Another example of a structural intervention to address sex work is the 100% condom policy established in Thailand (and implemented in the Dominican Republic). This is considered a structural intervention to address sex work because the impetus to enforce this policy was put on brothel owners, thereby reducing further vulnerability for sex workers and creating an overall atmosphere that promoted safe sex. Citation: Sommer & Parker(2013)· Chapter 9: The 100% Condom Use Programme: a structural intervention to prevent HIV and sexually transmitted infections in Asia by W Rojanapithayakorn and R Steen

Structure

Structure refers to all of the factors outside of the will of an individual that influence their behavior. Structure is wide in scope and include macro rules like the law, the economy, and cultural forces. These same factors can operate at more successively more proximal levels, like state, city, and neighborhood. As structure is conceptualized more proximally to the individual, it is more and more difficult to differentiate from agency. For example, the relationships a person has are a result of the people around them but individuals also make choices about who they enter into relationship with and what that relationship will look like. Structural interventions are important because they achieve population level change by changing culture/climate in a way that individual interventions often fail to do. In public health, the goal is population level change. Lecture 2: What are Structural Approaches Cite: Farley reading Chapter 9: (Sommer and Parker, 2013) 100% condom use program in Thailand as a means to reduce HIV infection rates.

Social construction of race

The concept of "race" exists not in biology and is only tangentially a product of nationality or ethnicity; race, as it were, is "socially constructed," or defined entirely by the community which is employing it. As a social construction, race defines individuals categorically and assigns them roles based on their categorical assignment. These categories are "agreed upon" by society in that they are tacitly accepted as truth, despite having no definitive xxxxxx. A social construction means to imply that a society gives meaning to a concept that has no intrinsic meaning on its own; the social construction of race refers to the ways in which we understand what it means to be of a given "race" based on the consensus-drawn categories. Race, however malleable and constructed by society, remains an important determinant for health disparities, often because of its confluence with class. ● "the idea of race and its persistence as a social category is only given meaning in a social order structured by forms of inequality— economic, political, cultural—that are organized by race" Omi, 2001 as quoted in Smedley ● North American concept of race is the notion that each race has its own forms of social or cultural behavior that contribute to the 'ideology of race' ○ In this way, racial groups are biologically discrete and physical characteristics become markers; Races are naturally unequal, must be ranked hierarchically; Each race has distinctive cultural behaviors linked to their biology; Differences among races are profound and unalterable; Racial classifications are stipulated in legal and social system ● Race is neither a biological construct nor a proxy for class, but rather a distinct concept similar to caste (Kawachi Daniels and Robinson References: Lecture 5: Race/Ethnicity Smedley article: made it up at a point when we needed it to happen :) Smedley, A., & Smedley, B. D. (2005). Race as biology is fiction,

Sex industry

The sex industry is an economic enterprise which involves the commodificaion of sexuality and sexual acts. Participants in the industry may be either providers or consumers who are involved in the sale or purchase or sex or sex-related services. The sex industry may function within the law, and in these cases may be subject to regulation and monitoring that potentially improve the public health by reducing potential harm surrounding sex work and the purchase of sex. In other contexts, sex work is illegal and/or criminalized, creating an atmosphere that may chill the ability for sex workers and patrons to protect their health. ??? Class examples of sex industries include tourists in the Dominican Republic seeking "authentic" same-sex experiences with local men (Kerrigan, 2006). Economic enterprise that is multifacted and varies depending on local context. Pornography, sex workers, Empowerment and oppression paradigm The business of sex and transaction around various aspects of sec Kerrigan et al (2006) Environmental-structural interventions to reduce HIV/STI risk among female sex workers in the Dominican Republic. American Journal of Public Health, 96(1), 120-125. Example: Lectures:

Sexual Projects

The way that people use their bodies to achieve other desired social ends (Hirsch). This is something that people 'do' and also 'perform', both deliberately and thoughtfully. People have sex a variety of reasons and, in most cases, it is not for health reasons. It can be viewed as a way that agency fits into structure because although expression of sexuality can be hindered by its social organization, women and men can both respond to these constraints by embarking on sexual projects that defy what is considered 'acceptable'. In order to change the behaviors that people are participating in (from unsafe to safe, for example) you must understand their motivations for such behaviors. In "Sexuality, Culture and Society: Shifting Paradigms in Sexuality Research", it is suggested that understanding the reasons people use to their bodies to achieve social ends is an integral part of implementing interventions to change behavior. An example of 'sexual projects" is shown in Hirch's work on Dellagado whereby condom use is foregone by couples as a means of signifying intimacy despite one or both partners knowing that this action may result in heightened HIV risk. Lecture 4: Sexuality

Structural aspects of racial inequality

This key term relates to the idea of #19, in that race is socially constructed and nowhere in the world does it exist concretely outside of society. While race is widely perceived to be about biology and ethnicity something that can adopted or altered in different situations, what race "is" has changed over time, illustrating its social construction. That racial disparities can be identified in a number of social systems, including health, education, housing, law enforcement, etc. show the structural aspects of racial inequality. These are the circumstances under which laws and policies are designed and/or implemented in such a way that they disproportionately burden certain identifiable groups more than others, creating and maintaining different aspects of racial inequality (also: institutions that construct and are constructed by our ideas of race, and perpetuate the ideas we have about inherent differences in race; any institutionalized racism that produces population-level effects of marginalization like red-lining). Examples of structures in which racial inequalities exist and are perpetuated included stop and frisk (New York), redlining in housing districts (Chicago), mass incarceration, public funding for schools, various health disparities outlined by Williams & Jackson inlcuding homicide, heart disease, cancer (week 5 lecture). EX 1) Williams and Jackson approach racial inequalities in health as "understood not only in terms of individual characteristics but also in light of patterned racial inequalities in exposure to societal risks and resources." In particular, residential segregation/redlining has a lot to do with income level, access to good education, access to healthy foods. As housing structures exist to segregate black and white neighborhoods, related structural inequalities produce increased vulnerabilities for minority groups. EX 2) The macroeconomic policies in South Africa described by Coovadia illustrate how economic disparities between races, starting in the apartheid era where black citizens were exploited to generate wealth for white minority, have continued into present policies that promote growth alone without redistribution. This advantage to the already advantages creates an unlevel playing field where racial inequalities in income, wealth, and health continue. Lecture 5: Race/Ethnicity Williams, D. R., & Jackson, P. B. (2005). Social sources of racial disparities in health. Health Affairs, 24(2), 325-334. Coovadia, H., Jewkes, R., Barron, P., Sanders, D., & McIntyre, D. (2009). The health and health system of South Africa: historical roots of current public health challenges. The Lancet, 374(9692), 817-834.

What is a structural approach?

To articulate a reasonable structural approach, need to be able to understand how social factors shape health outcomes Structural approaches, in contrast to individual approaches, locate problems of public health in the context individuals are set in as opposed to the individuals themselves. Therefore, where individual approaches to public health problems investigate and intervene on how the individual produces his own health, structural approaches to investigate and intervene on processes outside of the individual which affect his/her ultimate health behavior. Lecture 2: What is Structural Approach Readings: Sommer & Parker (2013) Chp 2, 4, 6 Blankenship, K. M., Bray, S. J., & Merson, M. H. (2000). Structural interventions in public health. Aids, 14, S11-S21.

Improved water & sanitation

Water, sanitation and hygiene are frequently neglected but essential elements that contribute to population health. Improved water and sanitation refers to efforts to provide water that is both clean (low in contaminants and coliform count) and accessible (to reduce the amount of time and effort required to acquire water). Increased quantities of accessible, clean water allow communities to allocate more of their water to hygiene, which can contribute to decreased incidence of hygiene-related diseases. Clean drinking water also reduces the occurrence of diarrheal disease, which is one of the leading contributors to high under-five mortality in developing countries. Where diarrhea-related mortality doesn't occur, there is still morbidity; which each episode of diarrhea experienced, a child experiences stunted cognitive and physical development compared to a healthy peer. In addition to clean water, sanitation must also be addressed. Safe latrines and increased/improved handwashing can provide significant improvements in health when complex infrastructural changes may currently be impossible. · Way more cost effective solution to big publis health issues rather than traditional interventions we use for some of the biggest diseases out there · As types of interventionsàhouses, community · What is means to intervene at different levels · Quantity, quality, access · People that have to go get water · Range of kinds of interventions, elements of those interventions and what they would change, example or two of technology · Implications of improved ater and sanitation and why its good Dealing effectively with HSW has the potential to reduce child mortality, one of the more recalcitrant health statistics, by a third. (Bartram 2010) · Most cost effective solution; comorbid worsening HIV/chronic · Context-specific for improvements (spectrum) · Community intervention · Access, increase quality, increase quantity, hygiene, time looking for water (productivity), social ramifications (widening gender inequalities) ***Interventions and what would those intervention change** -Give examples of improvements -Implications of interventions **Look at Summary Slides** Lecture 13: Water and Sanitaion Citations: Bartram, J., Lewis, K., Lenton, R. & Wright, A. (2005) Focusing on improved water and sanitation for health. Lancet, 365 (9461), 810-812. Bartram, J., & Cairncross, S. (2010). Hygiene, sanitation, and water: forgotten foundations of health. PLoS medicine, 7(11), e1000367. Sommer & Parker(2013) Chp 7: Water in South Africa municipalities

Bullying legislation as an example of the usefulness of health disparities for coalition building

Which groups have led/pressed for anti-bullying laws and regulations? · What is the expressed purpose of these laws and regulations? o Reduce youth suicide o Reduce school-leaving · Which groups are protected by these laws and regulations? · Bullying is an emergency because there are these · Making bullying into a health issue has brought people on board that otherwise may not have been on bored for something that seemed gay specific rather than health specific · How can you be for kids killing themselves · Health issue much less political than gay issue · Frame issue as health issue: opens doors for broader coalitionbased) · Safer political territory · Health disparities: very depoliticized way of talking about inequalities -Shared interest/ Solidarity · In Hatzenbuehler & Keyes(2012), we learned that anti-bullying policies that are INCLUSIVE of sexual orientation are associated with reduced prevalence of suicide attempts among LGB youth (high school participants). o Outcome: After 31,852 11th grade students(1,413 LGB youth) were surveyed in Oregon from 2006-2008, the findings looked out the result of the 34 counties in the Oregon Health Teens survey and whether the respective schools had inclusive anti-bullying policies of sexual orientation bullying and its association with suicide attempts in LGB youth. o LGB youth living in counties with fewer school districts with INCLUSIVE anti-bullying policies were 2.25 times MORE likely to have attempted suicide within the past year compared to those living in counties where more districts had more policies. So we can learn from this study that inclusive anti-bullying policies in schools are associated with reduced risk for suicide attempts among LGB youth. -Take-aways: o Because we are aware that inclusive anti-bullying policies in high schools have a protective effect for mental health of LGB youth, how can we use this knowledge to decrease the health disparities experienced by the LGB youth in the country? - Implement structural interventions in schools and community - Take the momentum and capacity building from LGB youth and concerned parents to create widespread legislation in schools and community to prevent bullying and discrimination against LGB youth - Use the concept of minority stress model for capacity building and community partnership - Connolly argues that EXPLICIT language that protects anti-gay bullying messages is absolutely necessary to protect LGB youth against mental health disparities and for schools to establish that LGB are equally as important as their heterosexual counterparts through enforcement such policies(Connolly, 2012). - We can begin to shape and normalize that anti-gay bullying will not only NOT be tolerated in schools but within the community as well. - We need to push for explicit, unambigious language legislation that anti-gay bullying will not be tolerated. -Title 6 and Title 9 do NOT protect LGB youth in schools. Citations: Connolly, L. C. (2012). Anti-Gay Bullying in Schools-Are Anti-Bullying Statutes the Solution. NYUL Rev., 87, 248. Hatzenbuehler, M. L., & Keyes, K. M. (2013). Inclusive anti-bullying policies and reduced risk of suicide attempts in lesbian and gay youth. Journal of Adolescent Health, 53(1), S21-S26. Lecture 12: LGBT rights

Combination prevention

combination prevention- interventions that include both biomedical and social components; combine individual biomedical and behavioral interventions with structural interventions (addressing social, cultural, physical environment, political, legal, and/or economic factors) ● Combination prevention public health interventions "offer the best prospects" for addressing public health challenges because they address complex issues on multiple levels, and as such more effectively impact a more diverse target population (UNAIDS) ● We spoke of combination prevention efforts in class specifically related to combining biomedical interventions with anti-stigma interventions, but they can be applied in a diverse range of contexts (Hirsch class 7) ● example- Reducing risk of HIV among FSW's in the DR. Biomedical interventions- condom usage, STI screening and treatment Behavioral- encouraging 100% condom usage with sex workers and teaching condom usage or no exchange Structural- communities of sex workers encouraging solidarity, environmental cues including posters and condom availability in sex establishments, policy enforcement where sex establishments were checked for compliance and fined if in violation (Kerrigan Barrington and Moreno) ● example- WASH interventions. Biomedical- safe drinking water and proper sanitation facilities to prevent incidence of waterborne illness Behavioral- teaching communities how to use only clean water sources and toilet facilities, teach handwashing to prevent spread of disease Structural- install said facilities in places easily accessed by target population, make using facilities more appealing than not using them (keeping them clean, in working order) (Hirsch Class 13) ● example- The Songachi Project. Biomedical- condom use Behavioral- normalization of condom use, peer education, challenging police behavior to be in line with the law, building up self-worth of sex workers Structural- communities of sex workers, microfinance options to empower sex workers economically, labor rights for sex workers (Swendeman and Jana) Citations- ○ Sommer and Parker. (2013). Structural Approaches in Public Health Ch 10. Swendeman, Dallas, and Smarajit Jana. 2013. The Sonagachi/Durbar Programme: A prototype of a community-led structural intervention for HIV Prevention. ○ Sommer and Parker. (2013). Structural Approaches in Public Health Ch15. Kerrigan Barrington and Moreno. Developing and Evaluating Structural-Environmental Interventions to Reduce HIV Risk Among Female Sex Workers and their Sexual Partners in the Dominican Republic ○ UNAIDS. (2010). Combination HIV Prevention: Tailoring and Coordinating Biomedical, Behavioral, and Structural Strategies to Reduce New HIV Infections. ○ Hirsch, Jennifer. (2014 March 8). Structural Approaches in Global Health Class 7. Lecture conducted at Columbia University, New York, NY. ○ Hirsch, Jennifer. (2014 April 24). Structural Approaches in Global Health Class 13. Lecture conducted at Columbia University, New York, NY.

Structural interventions to address stigma/discrimination

o Structural level: socio-political environmentàl policy driven - Meant to change social conditions that give rise to stigma - Alter cultural institutions and reduce barriers to education, healthcare, & housing (Cook et al., 2013). - Strength: potential to impact large # of people · Interventions Examples: o (1) Legal/policy interventions: use legislation to protect and normalize stigmatized group. -EX: Civil Rights Act of 1964: banned discrimination by race, color, religion, national origin for voter registration and public service. Hospitals had to stop racially discriminatory practices by 1966 in order to receive Medicare payments. Outcome: drop in mortality rates of AA in South from 1960-1970s. -EX: Title 9 Educational Amendment Act of 1972 banned discrimination of academic programs, specifically protecting sexual minority students. -EX: Rental vouchers to tenant-based housing programs for low SES families decreased depression, anxiety and health of those individuals. -EX: Laws protecting LGBT such as anti-bullying or hate crimes helped address mental health issues, suicides, depression among LGBT youth. o (2) Advertising/Social marketing: attempt to normalize stigmatized group and change public opinion on a large scale -Address homophobia, mental health issues. 2 years after a "See Me" campaign emerged in Scotland to address mental illness, media normalized mental illness. Outcome; survey showed that 11% drop in people agreeing that pubic should be better protected from people with mental health problems and drop from 32% to 15% in those who believed that people with mental illness are dangerous. Ultimately, mental illness was less of a taboo and more normalized through social marketing. - EX: California and New Jersey require physicians to undergo cultural competency during medical school & training prior to providing care. - (Not in readings, my own example): HIPAA law that came about to protect HIV + patients from disclosure or impacting housing, employment opportunities. HIPAA is now used to protect all patients from unlawful disclosure of ANY information in their charts by healthcare personnel Citation: Cook, JE, Purdie-Vaughns, V, Meyer, IH, JTA Busch. (2013). Intervening Within and Across Levels: A Multilevel Approach to Stigma and Public Health. Social Science and Medicine (in press). Monks story (below) Aggleton, P., Wood, K., Malcolm, A., & Parker, R. (2005). HIV-related stigma discrimination and human rights violations: c

Shared interests/solidarity

shared interests/solidarity- building a support network around an issue because of shared interests in a target population or cause, even if the causal narrative is different regarding the issue ● advancing political agendas often requires the support of many groups/peoples- this allows for issues to appeal to a diverse range of groups and thus builds political pressure for change ● example- anti-bullying legislation can be seen as a part of the LGBT rights agenda, but can also be viewed from a child welfare standpoint, anti-school violence (Class 12) ● example- women's rights and LGBT rights movements coalesced on the intersection of gender inequality issues "hierarchical power relations among masculinities and gender identities... rely on intertwining oppression of women and non-heterosexual men" (Class 3) ● Brazil reading?? ● Bulling-->parents and gay adults

Stigma

● Parker & Aggleton: as a process, an active struggle vs. a static construction - if it's changeable then opportunity for structural intervention; the kind of change... it's not imposed on people, but a dynamic between people ● Stigma as power (process not attribute), community mobilization an effective response to HIV/AIDs, from the people who are disempowered, not a complete response Stigma vs. culture ● Culture is a much broader concept ● Is any part of stigma not captured by culture? ○ Stigma is PART of culture (Venn Diagram) Social Inequality ● Stigma causes social inequality, the ways in which stigma limits access to resources ○ Ex: Occupational interventions (Yang article) - help those with mental illnesses Is discrimination related to and different from stigma? ● Discrimination is the manifestation of stigma - leads to structural interventions Pathways that link stigma, discrimination and schizophrenia ● Culture: history, religion ● Cultural value, fear or loss of faith, ability to maintain social networks ● Yang: Stigma - infantilize schizophrenia Multiple dimensions of stigma ● People who are more advantaged are more responsive to stigma ● Ex: Stigmatizing smokers, but it works · -negative characteristic that is applied to people or population; not static; reinforces and/or creates marginalization; way to make other people lower in relation to yourself Aggleton and Parker 2003, pps 8-12