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This paper points to an underexplored relationship of reinforcement between processes of quantification and digitisation in the construction of mental health as amenable to technological intervention, in India. Increasingly, technology is used to collect mental health data, to diagnose mental health problems, and as a route of mental health intervention and clinical management. At the same time, mental health has become recognised as a new public health priority in India, and within national and global public health agendas. We explore two sites of the technological problematisation of mental health in India: a large-scale survey calculating prevalence, and a smartphone app to manage stress. We show how digital technology is deployed both to frame a 'need' for, and to implement, mental health interventions. We then trace the epistemologies and colonial histories of 'psy' technologies, which question assumptions of digital empowerment and of top-down 'western' imposition. Our findings show that in India such technologies work both to discipline and liberate users. The paper aims to encourage global debate inclusive of those positioned inside and outside of the 'black box' of mental health technology and data production, and to contribute to shaping a future research agenda that analyses quantification and digitisation as key drivers in global advocacy to make mental health count. [ABSTRACT FROM AUTHOR]

Global health organisations are increasingly involved in large-scale health interventions in countries in the Global South, partnering with states to implement programmes to strengthen national health systems and promote Universal Health Coverage (UHC). Drawing on an ethnography of a large-scale global health partnership between the Zambian state and the Clinton Foundation, this paper examines the novel configurations of sovereignty that are created by these large-scale global health partnerships. It shows how officials from the Clinton Foundation came to believe that senior Zambian government actors had granted them the authority to implement the programme outside of the formal channels of the government health system. I conceptualise this as an informal mode of 'outsourcing sovereignty' and show how it led Clinton Foundation employees to behave as de facto state actors in rural Zambia. This paper contributes to the broader critical task of describing and analysing new forms of governmental pluralism in contemporary global health and highlights some of the politically troubling consequences when sovereignty is informally outsourced in this way. [ABSTRACT FROM AUTHOR]

When trying to understand childhood obesity, policymakers and healthcare professionals most often make use of behavioural sciences and biomedical perspectives. This approach assumes that fatness is unhealthy and caused by people making 'bad choices' about their diet and physical activity. Increasingly not only parents, but also children, are considered to be individually responsible for their weight, their health, and through that, for the 'obesity epidemic'. Drawing on critical obesity/weight studies and practice theory, this paper challenges the individualistic and weight-based view of health, and the heuristic of 'individual food choice', and through that such a framing of childhood obesity. It does so by focusing on the experiences of young people medically identified as overweight, who are trying to lose weight. Looking at two domains of children's lives, their family and peers, the paper demonstrates how young people experience and negotiate the individualized health advice, and what sort of consequences this has for their daily lives, and their mental and physical wellbeing. The article is based on observations of interactions between families and healthcare professionals, conversations with children and parents, as well as participant observation at youth summer weight loss camps, which were part of a larger ethnographic research project conducted in 2018–2019 in Poland. The paper concludes by proposing to reframe how we think about childhood obesity, and consider young people's knowledge and lived experiences when re-designing policy interventions and wellbeing promotion programmes, that is, to work with, and not on, children. [ABSTRACT FROM AUTHOR]

In this paper, we outline a critical reparative justice/care approach to adolescent reproductive health as an alternative to the standard public health response to 'teenage pregnancy'. Joining an increasing body of critical scholarship that calls for nuance in understanding reproduction amongst young people, we draw, in this paper, on data generated from an ethnographic study conducted in antenatal care units in an Eastern Cape township in South Africa. To illustrate the approach we propose, we home in on five case studies that highlight the variability of young women's lives, the multiple injustices they experience, and the agency they demonstrate in negotiating their way through pregnancy and birth. Injustices evident in these cases centre on sexual violence, rape myths, education system failures, health system failures, shaming and stigmatising practices, socio-economic precariousness, absent male partners, and denial of services. We outline how the reparative justice approach that highlights repair and support for social and health injustices at the individual and collective level as well as at the material and symbolic level may be taken up to ensure reproductive justice for young pregnant women. [ABSTRACT FROM AUTHOR]

Controlled Organ Donation after Circulatory Death (DCD) was re-introduced in the UK in 2008, in efforts to increase rates of organs for transplant. Following reintroduction there were debates about the ethics of DCD, leading to production of legal and ethical guidelines. Today, DCD makes up 40% of deceased organ donors, leading to claims that the UK has 'overcome' its ethical challenges. However, there is little understanding of how DCD works in practice and the ethical implications of making DCD routine in the context of the NHS. This paper draws on data from an ethnographic study examining the practices of DCD in two acute NHS Trusts in England. Interviews with Intensive Care staff and Specialist Nurses in organ donation, observations of organ donation committee meetings and analysis of Trust documents were conducted. Findings reveal that the routinisation of DCD has created new ethical issues relating to interactions between organisational timeframes for DCD and (under)resourcing for, and de-prioritisation of, donation within an NHS subject to austerity. They include: the perceived burden on families and implications for consent when there are delays in the donation process, due to theatre space and retrieval team shortages; family and staff distress when death does not happen 'on time'; and the problem of where to take patients who do not die in time to donate. I argue these temporal-ethical issues are likely to become heightened as potential donor rates increase with the new opt-out legislation, unless the resourcing required to deal with these problems are also addressed. [ABSTRACT FROM AUTHOR]

The past two decades have seen an increasing role for the UK community and voluntary sector (CVS) in health promotion in disadvantaged areas, largely based on assumptions on the part of funders that CVS providers are better able to engage ‘hard-to-reach’ population groups in services than statutory providers. However, there is limited empirical research exploring CVS provider practices in this field. Using ethnographic data, this paper examines the experiences of a network of CVS providers seeking to engage residents in health-promoting community services in a disadvantaged region in the North of England. The paper shows how CVS providers engaged in apparently contradictory practices, fluctuating between an empathically informed response to complex resident circumstances and (in the context of meeting externally set targets) behavioural lifestyle approaches to health promotion. Drawing on concepts from figurational sociology, the paper explains how lifestyle drift occurs in health promotion as a result of the complex web of relations (with funders, commissioners and residents) in which CVS providers are embedded. Despite the fact that research has revealed the impact of targets on the work of the CVS before, this paper demonstrates more specifically the way in which monitoring processes within CVS contracts can draw providers into the neoliberal lifestyle discourse so prevalent in health promotion. [ABSTRACT FROM PUBLISHER]

This paper draws upon the notion of slow emergency as a framework to interpret ethnographic and qualitative findings on the challenges faced by Puerto Ricans with chronic conditions and health-sector representatives throughout the island during and after Hurricane María. We conducted participant observation and qualitative interviews with chronic disease patients (n = 20) health care providers and administrators (n = 42), and policy makers (n = 5) from across the island of Puerto Rico in 2018 and 2019. Many Puerto Ricans coping with chronic diseases during and after María experienced bureaucratic red tape as a manifestation of the colonial legacies of disaster management and health care. They describe a precarious existence in perpetual 'application pending' status, waiting for services that were not forthcoming. Drawing on ethnographically informed case examples, we discuss the effects of these bureaucratic barriers on persons with three chronic conditions: renal disease, opioid dependency, and HIV/AIDS. We argue that while emergency management approaches often presume a citizen-subject with autonomous capacity to prepare for presumably transient disasters and envision a 'post-disaster future' beyond the immediate crisis, Puerto Rican voices draw attention to the longer, sustained, slow emergency of colonial governance. [ABSTRACT FROM AUTHOR]

This paper describes how a study using institutional ethnography (IE) was used as a decolonizing method of inquiry in a rural Indigenous community in Canada. IE honors lived experience, reveals institutional and colonial practices, provides clear empirical evidence, and can offer clear recommendations that can benefit Indigenous communities. At the heart of decolonizing research is the task of shifting whose knowledge is privileged – from those with power (often researchers) to those who are being researched (those subject to the effects of colonization). To highlight how IE can be used as a decolonizing method of inquiry, the authors of this paper (a) point out common pitfalls of academic research and knowledge translation (KT) practices in Indigenous health; (b) highlight decolonizing research principles and how IE can be a decolonizing method of inquiry; and (c) share an example to illustrate how IE was used in a decolonizing health study in a First Nations community context. This paper also outlines critiques of mainstream research and KT practices, highlights principles for conducting research with Indigenous people in Canada, and further discusses how IE is well positioned to facilitate both decolonizing research and strategic KT. [ABSTRACT FROM AUTHOR]

Since the 1990s, researchers have used community-based participatory approaches to achieve outcomes relevant to local communities, to build collaborative and sustainable research infrastructures, and to address disparities in knowledge production. Notwithstanding these strengths, communities and researchers have questioned its success in addressing power imbalances inherent in collaborative research encounters. In this methodological paper, we describe a novel community-based program science approach to guide an interdisciplinary research project on HIV self-testing among men who have sex with men in three Kenyan counties. Drawing on ethnographic field notes, we detail how community researchers and their academic and programmatic partners collaborated through all phases of the research process, including research design and data collection. Importantly, community researchers also played an integral role in data analysis and dissemination, going well beyond the conventional role of 'community engagement' in global health research. We also present findings from qualitative interviews conducted by community researchers with their peers to inform the rollout of HIV self-testing kits in their respective county-contexts. Our approach highlights that engaging community directly in evidence production allows research findings – owned and generated by communities on their own behalf – to be fed more swiftly and effectively into community-led program delivery. [ABSTRACT FROM AUTHOR]

The author examines how the rise of evidence-based techniques are affecting the interventions designed to respond to current global health problems. Topics discussed include several research on the production, negotiation and valuation of the different forms of evidence across a range of health contexts, the processes that guide the new practice of global health, and information on the Millennium Development Goals.

This paper explores public health policy implementation through partnership working at the local level by examining how local actors from public health, and the wider workforce make sense of and work on social inequalities in health. An ethnographic case study was used to examine policy implementation in one local strategic partnership in north-west England during a period of significant resource constraint. Semi-structured interviews were the primary method of data generation. Sensitising concepts from figurational sociology were used to develop a theoretical account of how local policy implementation directed at narrowing social inequalities in health tended to give rise to relatively fragmented and short-term services, projects and practices, which focused on lifestyle factors and behaviour change. Theorising partnership work as figurations goes some way to explaining the apparent paradox among participants who expressed a relatively detached appreciation of wider social influences, alongside emotional involvement in their work. This process of individualisation explains how local professionals tended to conceptualise health inequality and the social determinants of health as personal troubles. Individualisation meant that the social reality of working in partnerships on difficult issues was simplified. Thus, any scope for working on the social determinants of health tended to be overlooked. The extent to which this was intentional or a matter of struggling to see opportunities, or a mixture of the two, was difficult to discern. Although the policy landscape has changed, the findings give some insight into understanding how local collaborative processes reproduce local public health work underpinned by lifestyle choices. [ABSTRACT FROM AUTHOR]

This paper shows how in the past quackery was seen as a problem of remoteness and isolation while today it is global connects which provide the nourishing grounds for it. It looks at 'Dr Elsie' from rural Bushbuckridge, South Africa who uses a Quantum Resonance Magnetic Analysis Machine as a diagnostic tool to prescribe Chinese supplements. The paper describes how the practicing 'doctor' draws approval and a sense of legitimate professionalism from the economic success of her newly established business. Here, pseudo medical business becomes a conduit for social aspirations while she places the 'burden of proof' about the legitimacy of what she does with the very same people who the technology she uses deceives. The paper is framed by how the author's own sense of faithfulness as researcher is challenged by the difficulty to draw a clear line between authentic and pseudo health care. [ABSTRACT FROM AUTHOR]

This paper examines the multiple tensions arising in an Australian university and public sector collaboration that aimed to investigate an obesity intervention. A key site of conflict with the external collaborators emerged when we, the researchers, focusing on the experiences of marginalized local people, presented research findings that were at odds with the dominant understanding of obesity that framed the public health intervention. From those with a range of roles in the public sector, we received claims of misrepresentation and requests to change or not publicly release certain research findings. Drawing on the 'policy learning framework' of Dunlop and Radaelli, we examine these epistemic conflicts and point to the Achilles' heels of the 'engagement and impact' agenda. From the perspective of government, the inherent weakness stems from the lack of control in a partnership, and from the perspective of academics, it is the danger of undermining trust in universities and the knowledge academics produce, through the process of engaging with government and being party to research that is designed to shore up a position that government has already decided upon. This case study has implications for academic and government collaborators who may benefit from explicit planning about how to negotiate discord around the processes of learning that occur in and across research, policy, and practice. [ABSTRACT FROM AUTHOR]

There is a growing effort from a range of professionals and institutions to develop comprehensive integrated prison-to-community healthcare, discharge planning, and community re-entry support for inmates living with HIV. This paper draws from ethnographic data to explore the 'lived experience' of HIV-positive inmates in a US State prison system offering an integrated case management support programme. In the US, incarceration is critical for connecting socially marginalised people and those with health needs to certain rights and resources. We present the ways in which imprisonment enables a claims-making process against the state by allowing this group access to resources and rights connected to imprisonment, healthcare, and associated social welfare support. Offenders identified incentives underpinning their expressed desire or 'intention' to return to prison over time. Our findings suggest that this group of inmates has increased opportunity to access material, medical, and welfare resources when compared to the general inmate population and those outside the prison system. Multiple gaps remain in this group's sense of security in the community, ability to cope with the stress of everyday life, sustained support with substance dependency and, most importantly, consistent access to medical and welfare resources that enable them to live independently. Ironically, for many inmates living with HIV, incarceration offers a better chance of accessing public health services than living in the community. [ABSTRACT FROM AUTHOR]

This paper suggests that public health intervention research would benefit from more thorough considerations of the social dynamics in which public health interventions are embedded. Rather than simply asking ‘What works?’, researchers should examine the social effectiveness of intervention programmes; i.e. (i) the creation of shared understandings among researchers and practitioners and (ii) the ways in which programmes reconfigure social relationships. Drawing on the theoretical work of philosopher Charles Taylor and sociologist Marcel Mauss, we suggest that the term ‘the spirit of the intervention’ may enable researchers to further articulate – and hence discuss – the source of an intervention’s social effectiveness. The empirical impetus of the paper lies in our experiences as an interdisciplinary team of researchers, trained in social science and public health and now working within intervention research. We describe our attempts at reconciling the methodological requirements of an effect evaluation, modelled on the randomised clinical trial, with a process of intervention development grounded in ethnographic methods. In particular, we discuss how we have grappled with the schism between fidelity and adaptation, which is a key methodological issue in intervention research. While public health intervention research tends to conceptualise programmes as fixed and bounded entities, we argue that ‘the spirit of the intervention’ offers a conceptual starting point for reflections on programmes as on-going social processes. In order to capture and explore this dimension of public health interventions, a great deal of potential lies in a further engagement between intervention research, ethnographic methods and social theory. [ABSTRACT FROM PUBLISHER]

Can the careful implementation of global health research reduce the stigmatization of involved human subjects? This study analyses stigma in an Ebola vaccine clinical trial in West Africa that deployed complex community engagement strategies including a sensitization component. Qualitative research found that stigma against trial subjects manifested in various forms beyond the reach of these anti-stigma interventions. Drawing on and advancing Hacking's notion of 'looping effects', this paper argues that stigma was a product of a wider socio-historical context beyond the control of community-based interventions. This case prompts global health practitioners to think through the limitations of community-based interventions in practice. [ABSTRACT FROM AUTHOR]

Disease prevention and health care delivery, areas traditionally governed by the nation state and local communities, are increasingly being inhabited by ‘mobile sovereigns’ who carry a global currency of prevention strategies and treatments grounded in the universal standards of scientific evidence. Drawing on ethnographic evidence from research conducted on HIV in southwest China, this paper examines the impact of evidence-based science on the effectiveness of global health programming. It interrogates the intentions of global health partnerships and how the balance of power waged between those with money, science, and technical expertise, and those seeking assistance and resources, influences global health programming. Ultimately, the paper demonstrates the disconnect between the demand for a system of universal standards developed on the basis of scientific evidence and an appreciation for the local context, which shapes the way these standards should be modified for effective implementation of global health programs. [ABSTRACT FROM PUBLISHER]

We provide new empirical and methodological findings problematising evidence, evaluation and measurement when using asset-based approaches and co-production to improve health and address inequalities. The Assets Model was applied to develop and implement a co-produced methodological evaluation framework – Asset-Based Indicator Framework – measuring impacts of creative community engagement on health and inequalities. Our three-phased approach synthesised data from multiple sources over five years. Phase One identified existing health assets in Black and Minority Ethnic (BME) groups using a six-month ethnography; interviews with community organisation representatives (n=35); three BME focus groups (n=27). Phase Two identified conditions/actions for assets to be activated to maximise health for 'Roma' using community-based participatory action research (n=50). Phase Three turned to evaluation and indicators. The Asset-Based Indicator Framework was co-produced with self-identified Gypsies following an extensive literature review; expert interview; three participatory action-research workshops with professionals (n=20); two participatory action-research workshops with community members and professionals (n=49). Asset-based evaluation and measurement is complex due to narrow conceptualisations of evidence; epistemological and methodological incompatibilities; and lack of capacity and resources for sustained engagement. Understanding the granularity and interrelation of assets at individual, community and structural levels; identifying mechanisms through which change happens; and applying participatory and empowering methods to capture actions on assets leading to community-defined outcomes may not lead to meaningful changes without systemic change. The paper fills a clearly-defined gap addressing evaluation of community engagement within complex systems rather than clinical-medicine interventions with wide-ranging implications for international research, practice and policy. [ABSTRACT FROM AUTHOR]

Globally, indigenous peoples live with stark disparities in health when compared with national populations. The disparities arise from a combination of factors that relate to the social and economic determinants of health, combined with disenfranchisement, and a rapid destruction of indigenous health systems, forests, natural resources and indigenous knowledge. In Malaysia, the indigenous peoples, known as the Orang Asli or 'Original People', are often viewed by authorities as 'backward, ignorant and resistant to modern health services', and therefore responsible for their poor state of health. This view situates the problem in the indigenous community, with the state as the benevolent provider of progress and improvement including health services. Orang Asli responses to this benevolence ranges from pragmatism to resignation to resistance. Drawing on a two-year ethnographic study, this paper explores, from the perspective of the Orang Asli, the dynamics of state and non-state societies, the structure and role of indigenous health systems and the effects of socio-economic transition in shaping Orang Asli responses to modern health services. Already burdened with poorer health compared with the national population, there is a growing problem of non-communicable diseases among the Orang Asli. Addressing this will require a shift from the benevolent dependency-creating approach commonly adopted by state public health services to one that is inclusive, responsive and participatory. [ABSTRACT FROM AUTHOR]

Much research has examined the social constructions of overweightness and obesity in the broader society. This paper aims to contribute to this literature by examining the popular constructions of lifestyle behavior in direct-to-consumer advertising (DTCA) geared toward overweight and obese individuals. We are centrally interested in how pharmaceutical advertisements frame healthy behaviors as a solution to the experience of overweightness and in distinguishing how this framing differs from dominant discourses of health and obesity. We employ ethnographic content analysis to examine the healthy lifestyle discourses of 120 consumer-directed television ads for weight-related conditions. We identify two types of healthy lifestyle ads: (1) drug compliance ads, where behavioral changes around health management are largely restricted to the use of drugs, and (2) complementary drug use ads, where drug use and other types of healthy behaviors, such as diet and exercise, are regarded as essential components to a treatment regimen plan. In all ads, DTCA regards prescription drug adoption as a type of behavior change that, like diet and exercise, is necessary to minimize health risks. We find that to promote drugs, the pharmaceutical industry encourages lifestyle changes, and they do so by simultaneously drawing on and expanding upon the dominant public health discourse around healthy behavior. In finding that pharmaceutical companies frame drug use as a necessary component for overweight and obese individuals’ health management, this research contributes to the vast literature that problematizes normative views of the nature, causes, and treatment of obesity and weight-related conditions. [ABSTRACT FROM AUTHOR]

This paper explores the accountability relationships that arise between researchers, the community and community representative structures known as Community Advisory Boards (CABs). It draws on ethnographic and case study research that documented the history, recruitment, composition and representativeness of two CABs and their relationships with researchers and communities, carried out in two studies in Zambia between 2010 and 2014. The findings revealed contradictions, nuances and imbalances in actual community participation and representation. In both studies, the general population was not given the opportunity to participate in the election of their CAB representatives, and the elected CAB members themselves were initially told to have little or no direct contact with research participants whom they were supposed to represent (unless researchers dictated otherwise). Owing to the researchers’ monopoly of scientific knowledge, literacy and financial resources, power relations were imbalanced. Further, researchers were quick to ask for and formalise community commitment through the CABs whilst reticent about their own accountability to the community. Yet despite these imbalances and CABs lacking formal authority over researchers, CABs did have subtle powers arising from their wider influence in the community, which they could tap into to either support or resist research. To achieve a more balanced and open accountability between research stakeholders, more genuine participatory processes need to be built and sustained. [ABSTRACT FROM AUTHOR]

The Massachusetts experience of health care reform before the Affordable Care Act of 2010 reveals a moral economy of care in which expanded access was met by neoliberal demands for accountability and cost control. Publicly subsidized health insurance programs in the U.S. are deeply concerned with managing and regulating low-income residents’ access to and coverage for medications. By focusing our attention on the new forms of social relations invoked by specific techniques of governing, analyses of accountability can help us understand the ways in which subjectivities are shaped through their encounters with overarching social and economic structures. This paper presents qualitative findings from a four-year, prospective study that combined two waves of survey and chart-based data collection with four qualitative methods. Medicaid patients are made accountable to their medication regimens as they must track their supply and obtain refills promptly; regular blood tests carried out by health care providers verify their adherence. Both patients and their physicians are subject to cost savings measures such as changing lists of covered medications. Finally, patients struggle to pay ever-increasing out-of-pocket costs for their medications, expenses which may keep patients from taking their medications as prescribed. The fraught relationship between trust, accountability, and verification finds emphatic expression in the moral economy of health care, where the vulnerability of the sick and their hope for a cure confront policies designed to hold down costs. [ABSTRACT FROM PUBLISHER]

It is now widely accepted that context matters in evaluations of the health inequalities impact of community-based social initiatives. Systems thinking offers a lens for uncovering the dynamic relationship between such initiatives and their social contexts. However, there are very few examples that show how a systems approach can be applied in practice and what kinds of evidence are produced when this happens. In this paper, we use data from ethnographic fieldwork embedded within a multi-site mixed method evaluation to demonstrate how a systems approach can be applied in practice to evaluate the early stages of an area-based empowerment initiative – Big Local (funded by the Big Lottery Fund and delivered by Local Trust). Taking place in 150 different local areas in England and underpinned by an ethos of resident-led collective action, Big Local offers an illustration of the applicability of a systems approach to better understand the change processes that emerge as social initiatives embed and co-evolve within a series of local contexts. Findings reveal which parts of the social system are likely to be changed, by what mechanisms, and with what implications. They also raise some salient considerations for knowledge generation and methods development in public health evaluation, particularly for the evaluation of social initiatives where change does not necessarily happen in linear or predictable ways. We suggest future evaluations of such initiatives require the use of more flexible designs, encompassing qualitative approaches capable of capturing the complexity of relational systems processes, alongside more traditional quantitative methods. [ABSTRACT FROM PUBLISHER]

Children have been made a priority in Australian government obesity interventions, with programmes tending to focus on promoting behaviour change in food and exercise practices. This paper reports findings from ethnographic research with a group of Australian children aged 10–14 years living in a low socio-economic suburban setting. We propose that central to these children’s experiences of food and eating is the negotiation and management of hunger. Historically, disadvantage has been embodied and inscribed on children’s bodies in very visible ways, and the coexistence of hunger and obesity is part of this continuum. Despite considerable evidence of food insecurity in our research site, issues of hunger were absent in an obesity intervention underway at the time. We examine how hunger was felt in children’s lives, how it was managed and the ways in which messages about eating less, while eating more ‘healthy foods’, were at odds with the children’s experiences of hunger. Moreover, we argue that hunger and obesity in this context were doubly stigmatised, as children were very aware of how their hunger and their bodies marked them as different and disadvantaged. Attention to both the embodied and social impacts of hunger on children and their everyday relationships is key in formulating more sensitive, contextualised public health interventions. [ABSTRACT FROM PUBLISHER]

This paper explores how an array of HIV epidemic responders became embroiled in producing quantitative evidence for HIV interventions in India. Based upon extensive ethnographic fieldwork in Karnataka State, I examine the life history of the Gates-funded AIDS initiative in India known as Avahan as a case study to consider the social and political implications of large-scale, standardizing knowledge regimes enacted in the era of global health. Specifically, I analyze a sample of the key material artifacts that are implicated in the production of standardized knowledge in an attempt to illuminate the workings of what I refer to as ‘evidentiary sovereignty’. I argue that documents, forms, and other paperwork used to generate evidence in global health interventions neither merely reflect expert knowledge nor convey information about scientific standards but, rather,are integral to the re-instantiation of sovereignty.The effects of evidentiary sovereignty not only narrow the aperture of global health interventions to overlook the on-the-ground realities that shape health problems, but they also transform the very ground upon which communities responding to HIV epidemics conceive of and enact politics. As highly HIV-affected communities struggle with the bureaucratic demands of intensive form-filling and query agreed upon standards and systems of classification, a form of politicization of knowledge unfurls that pertains to the documents themselves. [ABSTRACT FROM PUBLISHER]

The MMR – maternal mortality ratio – has risen from obscurity to become a major global health indicator, even appearing as an indicator of progress towards the global Sustainable Development Goals. This has happened despite intractable challenges relating to the measurement of maternal mortality. Even after three decades of measurement innovation, maternal mortality data are widely presumed to be of poor quality, or, as one leading measurement expert has put it, ‘guilty until proven innocent’. This paper explores how and why leading epidemiologists, demographers and statisticians have devoted the better part of the last three decades to producing ever more sophisticated and expensive surveys and mathematical models of globally comparable MMR estimates. The development of better metrics is publicly justified by the need to know which interventions save lives and at what cost. We show, however, that measurement experts’ work has also been driven by the need to secure political priority for safe motherhood and by donors’ need to justify and monitor the results of investment flows. We explore the many effects and consequences of this measurement work, including the eclipsing of attention to strengthening much-needed national health information systems. We analyse this measurement work in relation to broader political and economic changes affecting the global health field, not least the incursion of neoliberal, business-oriented donors such as the World Bank and the Bill and Melinda Gates Foundation whose institutional structures have introduced new forms of administrative oversight and accountability that depend on indicators. [ABSTRACT FROM PUBLISHER]

In this paper, I examine the use of performance-based financing to scale-up HIV testing in men who have sex with men, or MSM, by global health initiatives in China. This mechanism, which ties financing directly to the achievement of targets and indicators, assures that measurable results are produced from health interventions and accounts for financial spending. On the one hand, its adoption into HIV programming in China articulates with broader shifts in global health that place currency on particular forms of evidence. At the same time, performance-based financing reshapes how HIV interventions are carried out and what counts in these programmes. The suturing of financing to outputs directs what gets counted and how, and as a consequence leads to the production of measurable results as an end in and of themselves. Based on 22 months of ethnographic research carried out in China, I explore the effects of this mechanism and, in doing so, ask what gets left out in the pursuit of evidence. In particular, I demonstrate how the demand for outputs undermines HIV prevention in MSM, thus risking the very lives these interventions are intended to save. [ABSTRACT FROM PUBLISHER]

In this paper, I demonstrate how autoethnography can be utilized as a methodology to conduct public health research. My argument is structured around an application of Jacques Lacan’s psychoanalytic theory which I see as supporting and extending a critical understanding of the so-called obesity epidemic and related issues. I argue that the body mass index (BMI) measure has achieved an unconscious position as a ‘Sovereign Good’ and, as such, provides the moral and ethical mechanism through which state-sanctioned science, via the wider weight-loss industry, prescribes people into a state of weight anxiety. I conclude that public health practitioners who find themselves promoting weight loss towards the ‘healthy’ range of the BMI are in an unethical position, one that should be entirely rejected. Instead I point to the ethics of desire as an alternative position that might help public health practitioners who are interested in actually improving public health. [ABSTRACT FROM PUBLISHER]

This paper presents the results of the qualitative phase of Healthy Foundations, a study that groups people according to their motivations to live healthily or otherwise, their lifestyles, and the circumstances that affect this. These segments are ‘Health Conscious Realists’, ‘Balanced Compensators’, ‘Live for Todays’, ‘Unconfident Fatalists’ and ‘Hedonistic Immortals’. The aim was to explore people’s attitudes and motivations to live healthily or otherwise and the targeted healthcare interventions appropriate for each segment. The qualitative phase involved two strands: (i) focus groups and immersion in-depth interviews and (ii) video ethnographic ‘pen portraits’. It provides robust insight into the five segments’ motivations and behaviour and how these are constructed within and influenced by the wider environment. It also enabled the segments to give their views of and design appropriate interventions aligned to their individual requirements, lifestyles and structural environments. It demonstrates the usefulness of the qualitative approach to health segmentations and enhances the case for methodological pluralism, and a critical perspective, to enable development of health-related behaviour change interventions and policy more widely. [ABSTRACT FROM PUBLISHER]

As a school subject, health education functions as a contemporary apparatus of governmentality by attempting to shape the health[y] conduct of young people. Currently, health education, along with many other institutions and programmes, is heavily shaped by neoliberal logics of risk. This paper is interested in exploring how these tenets shape versions of curriculum and classroom practices. The article draws on ethnographic data and the analytical device of governmental assemblages to consider how governmentalities are brought to life at their point of application; via teacher interviews and classroom practices. Analysis reveals that health education pedagogical assemblages are made up of the usual ‘neoliberal suspects’: risk discourses and strategies that attempt to individualise and responsibilise. However, accompanying these ‘usual suspects’ are a raft of melodramatic and affective intensities, including disgust and shame. These affective pedagogical assemblages are significant for scholars interested in understanding the governmental machinery of health education, and public health and health promotion more broadly, and its potential effects. [ABSTRACT FROM PUBLISHER]

In this paper, we examine how New Zealand children engage with public health agendas that seek to shape their understandings of health. We shed light on the ways children make sense of what they see, hear and come to know through public health ‘work’, and consider what effects this has for how they come to think of their ‘selves’ and relations with others. We pay attention to the way public health messages assemble, bolstered by dispositions, behaviours and ruminations expressed in schools, families and communities. Children’s talk exemplifies the sheer volume of public health missives saturating their worlds and the range of media used to reach into children’s lives. In many cases, children are ‘doing it for themselves’ in the sense that they are attempting to enact health imperatives about healthy eating, regular exercise and weight management. However, alongside the willingness of many to simply believe and enact health information, we draw attention to the capacity of some children to think through public health messages, negotiate and make sense of them in relation to their own lives. Despite the ubiquity and mantra-like quality of public health messages currently directed at children we contend they are variously interpreted and embedded in children’s lives. We regard the messiness and complexity of children’s engagement as affirmation that a critically informed variety of public health could provide opportunities for children to come to know health as more than simply eating the right foods and running a lot. [ABSTRACT FROM PUBLISHER]

Drawing upon qualitative and ethnographic data collected in the UK, this paper discusses how public discourses and concerns about food safety are negotiated into everyday domestic kitchen practices. While many participants demonstrated ‘behaviours’ or ‘practices’ which could be seen to contravene or fall short of official guidelines, this does not necessarily indicate ‘ignorance’ or lack of responsibility on the part of consumers. Indeed, when explored in detail, participants presented a range of reasons for engaging in what the UK Food Standards Agency regard as ‘risky’ practices. Their explanations point toward an understanding of the distribution of domestic responsibility in which a number of stakeholders are implicated, while simultaneously acknowledging their role as final arbiters of food safety in the home. [ABSTRACT FROM PUBLISHER]

It has been suggested that asset-based strategies could provide an opportunity to rethink the approach to public health; however, this may not be a viable option unless there is clear recognition of specific individual assets. Although there has been some consideration of assets within a child health context, this is limited and previous studies have not sought to identify assets from the perspective of the child. This paper reports on a study that drew on an ethnographic approach, using a photo-elicitation method, to facilitate the mapping of children’s internal and external assets from the viewpoint of children themselves. Two primary schools in the South-East of England were used to recruit 20 year five children (aged 9–11 years of age). The participants, 10 boys and 10 girls, were given disposable cameras and asked to take photographs of the activities that they enjoyed. The children’s photographs were used as prompts during individual semi-structured interviews. A constant comparative analysis facilitated the mapping of the children’s assets as the children described them; this process revealed one overall stabilising asset (‘My Family’) as well as eight internal and three external assets. All of the assets are presented within an original model, ‘I’m good’: the children’s asset wheel [CAW], which was developed from the findings. It is suggested that the CAW could complement previous asset-based work to facilitate the rethinking of approaches to the enhancement of children’s public health. [ABSTRACT FROM PUBLISHER]

Antibiotics are a routine part of everyday life in many contexts, contributing to the development of antimicrobial resistance (AMR). Our ethnographic research documents the ways that antibiotics have become a key part of everyday life for precariously employed urban day-wage workers living in a large informal settlement in Kampala, Uganda. We found that for many people, their daily work and ongoing health was entangled with antibiotic use; that is, people showed us how their antibiotic use cannot be separated from the realities of living in a politically, economically and environmentally degraded 'informal' landscape. Thinking through entanglement as itself a politics, we show how limited political power, inability to demand change, and inequitable access to good health care, are associated with high rates of infection and disease, precarious work, and polluted environments. Antibiotics, we argue, have become a way to negotiate the inequalities written into these informal urban landscapes; their use entangled with ongoing relations with labour, environment and bodily suffering. Through this approach, we show how antimicrobials are used in society, with an attention to how vulnerabilities, risks, and forms of abandonment and exclusion shape their everyday use. Antibiotic use is entangled with everyday life in informal settlements, and the politics that produce 'informality'. In Kampala today, the entanglement of antibiotics with life in informal settlements reveals how forms of urban segregation, life in 'slums' and their everyday acceptance, shape the pathways and uses of antimicrobials. [ABSTRACT FROM AUTHOR]

Global health policymakers have identified Myanmar as a source of high drug resistance and informal pharmaceutical markets in need of tighter state regulation. The World Health Organization drafted a Global Action Plan on antibiotic resistance (often referred to as antimicrobial resistance) that seeks to address it. Myanmar is one of over a hundred countries that has followed the World Health Organization's prescription and drafted its own National Action Plan. Through participating in the everyday life of a family pharmacy, we observed that in practice the outcomes of global plans for AMR, such as regulating access to antibiotics, are shaped by people's limited access to affordable health care, low salaries, and the military's authoritarian role in Myanmar politics. We followed how negotiations between state officials and drug vendors evolved towards a mutual understanding (as opposed to following written rules) after a Food and Drug Administration raid, intended to enforce the regulation of the sales of illegal medicines. Rather than uncritically pushing state-centric action, those working to promote the regulation of medicines must attend more carefully to how different modes of political authority and governance, combined with histories of health provision, shape drug policy in practice. Otherwise, they risk contributing, if not intensifying, already existing health and social injustices, whilst also failing to generate their intended outcomes, such as meaningful changes to antibiotic sales and reductions in resistance. [ABSTRACT FROM AUTHOR]

Consuming alcohol in night-time entertainment (NTE) precincts is a common practice for young adults in urban environments. Public health research often emphasises the 'harms' associated with drinking in NTE precincts and views these as being a product of the widespread availability of alcohol. However, this obscures more complex accounts of the various elements at play in young adults' drinking on a night out. Employing assemblage thinking and a meta-ethnography of published qualitative research in Australia, we analyse and assemble the socio-cultural and material elements that may coalesce in young adults drinking on a night out. We identify a broad range of elements in assemblages of young adults drinking, including norms, settings and places, social elements, and desirable effects. We suggest that public health researchers pay closer attention to the diverse range of socio-cultural and material elements in which young adults' drinking is entangled. We argue that assemblage thinking opens up new possibilities for maximising the social connection and pleasure that engaging in NTE precincts affords young adults while also minimising undesirable experiences. [ABSTRACT FROM AUTHOR]

Rates of HIV within marriages in Kenya remain high. While critical public health scholars have argued that socio-structural contexts shape HIV vulnerability, public health emphasizes neoliberal health management approaches that prioritize individual responsibility to avoid HIV risks. This article examines Kenya's marital fidelity campaign as a manifestation of neoliberal health governance techniques. It considers the sexual morality of the campaign including how the campaign frames extramarital risks and gender relations in marriage. Further, using ethnographic data from a cash-cropping community in rural Kenya, the article examines how participants' conceptions of marriage as a gendered site shape their everyday moral/rational reasoning that challenges public health's neoliberal logic of risk and responsibility. Participants deploy the social risk concept to show how they engage in reasoning that is informed by their social and material context. The article argues that public health should consider how the gendered social organization of marriages within specific political-economic contexts shapes HIV vulnerabilities as an alternative to neoliberal governmentality. [ABSTRACT FROM AUTHOR]

Full-body computed tomography (CT) screening came to Australia in 2002. Within a year, public access to self-referred full-body CT screening was withdrawn as a consequence of sustained professional and political pressure and legislative changes. We examine how self-referred full-body CT scans were made available to Australian consumers, and evaluate the social, cultural and system factors that contributed to their de-implementation. Using historical methodologies, insider accounts and an ethnographic content analysis of policy documents, statutory reports, grey and scholarly literatures, we show how the rapid de-implementation of full-body CT scans in Australia arose from interconnected social, cultural and system factors, and an unusual harm profile for the technology. In the Australian context, this case suggests that neither single actors nor robust health technology assessments are likely to be sufficient to protect people from the unwanted consequences of too much medicine. The coordinated interaction of multiple stakeholders achieved this unusual example of successful, early de-implementation. Each stakeholder exercised their authority within their respective remits to shape public perceptions of and access to the new CT screening service: it is possible that without the actions of each, the final de-implementation outcome may not have been achieved. These findings are timely, given growing concerns about overdiagnosis and the emergence of new forms of testing technologies. Against a background of technological optimism and commercial opportunism, a commitment to vigilance and cross-sectoral coordination across a range of decision-making roles and institutions will be key to efforts to prevent the harms of overdiagnosis. [ABSTRACT FROM AUTHOR]

Britain was the first country in the world to prescribe diamorphine (pharmaceutical-grade heroin) to heroin users as a treatment for opioid dependency. Known and admired internationally as the British System, Britain has a somewhat more ambivalent relationship to its own invention. Where patients were once prescribed diamorphine and other injectable opioids on an unsupervised basis, new patients are no longer initiated in this way and those existing 'old system' patients are under threat. Carrying out ethnographic research at an advocacy service for people who use drugs, I explore this threat as an onto-epistemological concern and the advocates' work to sustain these 'old' ways of knowing and being with diamorphine as a collective matter of care and action. Accounting for advocacy as a non-objective 'emboldening' of the individual to speak, the advocates draw our attention to the inequity of knowledge production and the collective act of speaking in an environment that is increasingly hostile towards these patients. As neoliberal political economies interact with stigmatising forces against people who use drugs, the article highlights the advocate's work as essential in allowing these patients' concerns to be heard where a threat to their prescription becomes a threat to their very way of living. [ABSTRACT FROM AUTHOR]

Engaging the community in initiatives to improve health and inequalities is a prominent feature of contemporary public health approaches. Yet, how ‘community’ might be differently interpreted and experienced through mechanisms of engagement is little understood, with potential implications for how the pathways of effect of such initiatives, and their impacts on health inequalities, might be evaluated. This study sought to explore how community was enacted through the delivery of an area-based, empowerment initiative underway in disadvantaged areas of England. An ethnographic approach was used to identify enactments of community arising around the core activities and decision-making processes of the resident-led initiative in two sites. Enactments comprised ‘boundary work’: the ongoing assertion and negotiation of boundaries around who or what was, and was not, eligible to contribute to decision-making, and / or benefit from the initiative. Boundary work arose around practices of connecting with and consulting residents, protecting locally defined interests and autonomy, negotiating different sets of interests, and navigating representation. The multiple, shifting enactments of community and its boundaries highlight implications for understanding processes of inclusion and exclusion inherent to community engagement, and for interpreting pathways between collective empowerment and improved health. The study also raises questions for evaluating similar complex, community initiatives, where community cannot be taken as a fixed analytical unit, but something continually in process through the interplay between the initiative and the wider context. This must inform interpretations of how, and for whom, community engagement might – or might not – improve health. [ABSTRACT FROM PUBLISHER]

In the United States, increased national attention has generated a wealth of public health and epidemiologic research examining disparities in African American children’s mental health services utilization. Research has not yet been extended to examining the social structural mechanisms that keep these disparities stable and in place. Drawing from a larger urban ethnographic field study exploring the ‘everyday’ of health and illness within and across African American families living in an inner city public housing community, in this article I document the narratives of four African American mothers to illustrate how social structural mechanisms shape their decisions to seek or not mental health services for their children. I frame mothers’ decisions in terms ofeveryday violence, drawing attention to the institutionalized injustices that are normalized and rendered invisible because of their routine pervasiveness. I conclude with a discussion of integrating structural interventions to modify or reduce disparities in African American children’s mental health services utilization. [ABSTRACT FROM PUBLISHER]

Many studies of blood donation have looked at the motives of donors, their relationship with the wider society and corresponding values such as gift-giving, altruism and responsibility. These underpin a rhetorical representation of person-to-person donation that neglects the many technical processes that take place between donation and eventual use and the material nature of blood itself. This ethnographic study, conducted in four UK blood donation sites, describes the various practices involved in routine sessions, rather than the motives or values or donors or staff. It focuses on the procedures and equipment that not only ensures blood is collected safely and efficiently, but the extent to which they determine the nature of the collected blood itself. Taking our cue from posthuman approaches, we argue donated blood as something that is ‘made’ only when it leaves the body; in other words, it is not simply extracted, but is constructed through specific practices. We illustrate how, as blood is separated from the body, it is increasingly depersonalised and reconstituted in order to have biomedical value. In this way, rather than reproducing the essentialist claim that blood is what social scientists often described as a ‘special kind of substance’, we point to the ways in which donated blood alters as it moves in time and space. We argue that such transformations occur in both symbolic and material realms, such that the capacity of blood to have both cultural meaning and clinical value is dependent on the fact that it is never stable or singular. [ABSTRACT FROM PUBLISHER]

Accountability and transparency are considered best practices within development cooperation frameworks characteristic of global health practice today. In this article, I ask: How do accountability and transparency work, and for whom? I develop three main arguments. Drawing on Geissler’s concept ‘unknowing,’ I first demonstrate that global health actors are aware, yet strategically obscure, the instabilities and problematics of data and indicators in Tanzania. Second, I suggest that multiple and contradictory forms of accountability are pursued by global health actors, while this multiplicity is often unspoken in order to render accountability frameworks legitimate to sustain the existing development cooperation system. Third, I argue that foreign and Tanzanian actors within the health sector perpetuate accountability and development cooperation frameworks which are neither cooperative, nor accountable to citizens and purported beneficiaries of aid, because doing so allows actors to pursue interests often unrelated to formal policy goals. [ABSTRACT FROM PUBLISHER]

This article reports findings from focus group conversations and in-depth interviews about the things that parents do to take care of their children’s health in Toronto, Canada. Our data demonstrate that within a single urban setting, parents are differently positioned to effectively find and engage existing healthcare resources. Parents’ ‘family health work’ is shaped by systemic expectations for health and institutional literacy and inter-institutional navigation skills that not all parents possess in equal measure. The intensive focus in Ontario paediatric healthcare settings on patient and parent education suggests increased interest in cultivating autonomous health information seeking and use strategies among parents. But the degree to which parents’ health-information seeking and use strategies are deemed effective depends on whether they are able to construct coherence between what they know about their child’s health and how to take care of it, and the knowledge the medical system requires to support diagnosis and treatment. Our research suggests that the healthcare system is only interested in information-seeking autonomy insofar as it supports patients’ engagement with the systems’ existing practices, frames of validity and service pathways. People who are unable to demonstrate health knowledge and work that support existing systemic processes cannot effectively use what they know and do to support their children’s health and wellness. [ABSTRACT FROM PUBLISHER]

Illicit drug use and homelessness among street-involved young people remain community and public health concerns, in part because of their association with ‘public disorder’, as well as increased encounters between youth, police, the criminal justice system, and the associated health-related harms. In the public imagination, illicit drug use, homelessness, and police encounters (including incarceration) are often understood as problems rooted in individual biographies. In general, there has been a lack of attention to the larger historical, institutional, and social-spatial contexts that converge across time, to increase young people’s risk of coming into contact with police and the criminal justice system. Drawing from a longitudinal ethnography with street-involved young people who use illicit drugs in Vancouver, Canada, we highlight two qualitative case studies that illustrate some of the ‘pathways’ to criminalization among this population. Specifically, these case studies reflect the complex linkages between child apprehension, foster care, homelessness, illicit substance use, and incarceration (juvenile detention and prison) across time. Our findings highlight the role of state interventions in perpetuating the marginalization that occurs across young people’s lives, in ways that increase their vulnerability to police and criminal justice encounters. [ABSTRACT FROM PUBLISHER]

This article offers a critical analysis of how to address social inequalities in mental health. In public mental health, inequalities are commonly construed as a problem of reach, implying that existing mental health expertise often fails to reach low-income groups. We discuss two critiques on the 'reachparadigm' in mental health promotion: the impoverishment of idioms of distress and the tendency to transform complex political issues into clinical ones that are assumed to be backed by evidence. Furthermore, we present the findings of our ethnographic research of an alternative approach to mental health promotion that used media storytelling focused on local knowledge and social context. Our analysis is guided by anthropological research on idioms of distress and sociological literature on health promotion and social inequalities. [ABSTRACT FROM AUTHOR]

A growing body of social science research has focused on the negative public health consequences of criminalizing the sexual transmission of HIV. I examine the criminalization of contagion in West and Central Africa and address a significant research gap:How do legislative environments that enable harmful laws to be applied become created in the first place?With stated aims of promoting human rights and public health objectives, HIV/AIDS-related laws have been created transnationally though the use of an omnibus model law. A group of legislative actors have problematized this United States Agency for International Development (USAID) funded model law, known as the USAID/Action for West African Region model law, or N'Djamena model law. This ‘harmonizing’ text led to the rapid spread of HIV/AIDS laws, including the criminalization of HIV transmission, across at least 15 countries in West and Central Africa between 2005 and 2010. The HIV model law was packaged and ‘sold’ to developing countries through the strategic use of best practice discourse. Best practice replications are enabled though a set of social and technological relations of use including the availability of mobile, standardizing texts. Although best practice standardization has been a key feature of global health institutions work activities in the HIV response over the past two decades, recent replications related to the criminalization of HIV transmission illustrate the potential public health dangers of ‘don’t reinvent the wheel’ thinking. I offer a normative critique of the transnational, text-mediated process that has produced highly problematic laws. [ABSTRACT FROM PUBLISHER]

Path-breaking scholarship has described how corporate control of food production and distribution is implicated in the global emergence of diets heavy in fats, meats and sugars. The ‘multinational food and beverage companies with huge and concentrated market power’ can be thought of as Big Food. Big Food’s presence in Kenya has expanded, and organizations have expressed concerns about the number of Kenyans who are obese. Despite these concerns, Kenya’s dietary profile does not show a clear picture of high fats, meats and sugars. This suggests that the structural factors that shape the organization of Kenya’s food supply need to be examined. By looking to the food regime approach, it is possible to understand how dietary patterns are a ‘reconstitution of material culture’, as trade arrangements shape diets in ways that make some foods seem traditional, while others appear to be new or exotic. By using the food regime approach, it is possible to understand how Kenya’s position in international trade influences food production and consumption, as well as how the Kenyan state has played a role in mitigating the Big Food diet. In this respect, the policies and practices that organize Kenyan diets are reflective of global-historical arrangements, but are also particular to Kenya. I base my argument on ethnographic research conducted in 2010 and 2014 in urban and rural areas, interviews, FAOSTAT statistics, scholarship, government documents, agency reports, newspapers and relevant food websites. [ABSTRACT FROM PUBLISHER]

In 2012 and 2013, Richmond and El Monte, CA, and Telluride, CO, became the first communities in the country to vote on citywide sugary drink taxes. In the face of massive spending from the soda industry, all three proposals failed at the ballot box, but the vigorous public debates they inspired provide valuable insights for future policy efforts. We analyzed local and national news coverage of the three proposals and found that pro-tax arguments appeared most frequently in the news. Advocates for the taxes focused primarily on the potential community health benefits the taxes could produce and the health harms caused by sodas. Tax opponents capitalized on the existing political tensions in each community, including racial and ethnic divisions in Richmond, anti-government attitudes in El Monte, and a culture of individualism in Telluride. Pro-tax arguments came mainly from city officials and public health advocates, while anti-tax forces recruited a wide range of people to speak against the tax. The soda industry itself was conspicuously absent from news coverage. Instead, in each community, the industry funded anti-tax coalition groups, whose affiliation with industry was often not acknowledged in the news. Our analysis of this coverage exposes how soda tax opponents used strategies established by the tobacco industry to fight regulation. Despite these defeats, tax advocates can take inspiration from more mature public health campaigns, which indicate that such policies may take many years to gain traction. [ABSTRACT FROM AUTHOR]

Khayelitsha, an economically marginal peri-urban settlement in Cape Town, is home to a number of ‘flagship’ public health interventions aimed at HIV/AIDS and TB. Alongside these high-profile, foreign donor-driven treatment and care programmes are a plethora of NGOs that provide a wide range of community-based carework. Some of these organisations are large, well funded and well connected globally, while others are run by a few unemployed women responding to care needs in their neighbourhoods. This article explores the ways that community health workers (CHWs) who work for these organisations understand and speak about their involvement in carework as volunteers, employees or managers of community-based care organisations. Many CHWs framed their work through discourses of gender, religion or culture (‘African-ness’). They also described forms of material or economic benefits of providing carework, but many were concerned that these might be seen as existing in tension with more socially accepted, altruistic motivations for care. We explore here how CHWs narrate and understand their roles and motivations as carers and members of a resource-constrained community. [ABSTRACT FROM PUBLISHER]