The potential importance of the built-environment microbiome and its impact on human health.

There is increasing evidence that interactions between microbes and their hosts not only play a role in determining health and disease but also in emotions, thought, and behavior. Built environments greatly influence microbiome exposures because of their built-in highly specific microbiomes coproduced with myriad metaorganisms including humans, pets, plants, rodents, and insects. Seemingly static built structures host complex ecologies of microorganisms that are only starting to be mapped. These microbial ecologies of built environments are directly and interdependently affected by social, spatial, and technological norms. Advances in technology have made these organisms visible and forced the scientific community and architects to rethink gene-environment and microbe interactions respectively. Thus, built environment design must consider the microbiome, and research involving host-microbiome interaction must consider the built-environment. This paradigm shift becomes increasingly important as evidence grows that contemporary built environments are steadily reducing the microbial diversity essential for human health, well-being, and resilience while accelerating the symptoms of human chronic diseases including environmental allergies, and other more life-altering diseases. New models of design are required to balance maximizing exposure to microbial diversity while minimizing exposure to human-associated diseases. Sustained trans-disciplinary research across time (evolutionary, historical, and generational) and space (cultural and geographical) is needed to develop experimental design protocols that address multigenerational multispecies health and health equity in built environments.

The hygiene hypothesis, the COVID pandemic, and consequences for the human microbiome.

The COVID-19 pandemic has the potential to affect the human microbiome in infected and uninfected individuals, having a substantial impact on human health over the long term. This pandemic intersects with a decades-long decline in microbial diversity and ancestral microbes due to hygiene, antibiotics, and urban living (the hygiene hypothesis). High-risk groups succumbing to COVID-19 include those with preexisting conditions, such as diabetes and obesity, which are also associated with microbiome abnormalities. Current pandemic control measures and practices will have broad, uneven, and potentially long-term effects for the human microbiome across the planet, given the implementation of physical separation, extensive hygiene, travel barriers, and other measures that influence overall microbial loss and inability for reinoculation. Although much remains uncertain or unknown about the virus and its consequences, implementing pandemic control practices could significantly affect the microbiome. In this Perspective, we explore many facets of COVID-19-induced societal changes and their possible effects on the microbiome, and discuss current and future challenges regarding the interplay between this pandemic and the microbiome. Recent recognition of the microbiome's influence on human health makes it critical to consider both how the microbiome, shaped by biosocial processes, affects susceptibility to the coronavirus and, conversely, how COVID-19 disease and prevention measures may affect the microbiome. This knowledge may prove key in prevention and treatment, and long-term biological and social outcomes of this pandemic.

Accounting for variation in and overuse of antibiotics among humans.

Worldwide, antibiotic use is increasing, but many infections against which antibiotics are applied are not even caused by bacteria. Over-the-counter and internet sales preclude physician oversight. Regional differences, between and within countries highlight many potential factors influencing antibiotic use. Taking a systems perspective that considers pharmaceutical commodity chains, we examine antibiotic overuse from the vantage point of both sides of the therapeutic relationship. We examine patterns and expectations of practitioners and patients, institutional policies and pressures, the business strategies of pharmaceutical companies and distributors, and cultural drivers of variation. Solutions to improve antibiotic stewardship include practitioners taking greater responsibility for their antibiotic prescribing, increasing the role of caregivers as diagnosticians rather than medicine providers, improving their communication to patients about antibiotic treatment consequences, lessening the economic influences on prescribing, and identifying antibiotic alternatives.

Motivations for pre-exposure prophylaxis uptake and decline in an HIV-hyperendemic setting: findings from a qualitative implementation study in Lesotho.

BACKGROUND: Pre-Exposure Prophylaxis (PrEP) has demonstrated clinical efficacy in preventing HIV infection, yet its uptake remains low. This study, conducted in five PrEP implementing districts in Lesotho, examined factors motivating persons at risk of HIV infection to adopt or reject PrEP when offered freely. METHODS: In-depth interviews were undertaken with stakeholders directly engaged with PrEP policy (n = 5), program implementation (n = 4), and use (current PrEP users = 55, former PrEP users = 36, and PrEP decliners (n = 6)). Focus group discussions (n = 11, 105 total participants) were conducted with health staff directly providing HIV and PrEP services. RESULTS: Demand for PrEP was reported highest among those at greatest risk for HIV acquisition: those in serodiscordant relationships and/or engaged in sex work. Culturally sensitive PrEP counseling was described as an opportunity to transfer knowledge, build trust, and address user concerns. Conversely, top-down counseling resulted in PrEP distrust and confusion about HIV status. Key motivations for PrEP uptake revolved around sustaining core social relationships, desire for safer conception, and caring for ailing relatives. The decline of PrEP initiation was driven by a combination of individual-level factors (risk perception, perceived side effects, disbelief of the drug's efficacy and PrEP's daily pill regimen), societal factors (lack of social support and HIV-related stigma), and structural factors related to PrEP access. CONCLUSIONS: Our findings suggest strategies for effective national PrEP rollout and implementation include: (1) demand creation campaigns which highlight positive aspects of PrEP, while simultaneously addressing apprehensions for uptake; (2) strengthening health provider counseling capacity; and (3) addressing societal and structural HIV-related stigma.

Effects of social network diversity in the disablement process: a comparison of causal inference methods and an outcome-wide approach to the Indonesian Family Life Surveys, 2007-2015.

BACKGROUND: Social networks (SN) have been proven to be instrumental for healthy aging and function as important safety nets, particular for older adults in low and middle-income countries (LMICs). Despite the importance of interpreting health outcomes in terms of SN, in many LMICs - including Indonesia - epidemiological studies and policy responses on the health effects of SN for aging populations are still uncommon. Using outcome-wide multi-method approaches to longitudinal panel data, this study aims to outline more clearly the role of SN diversity in the aging process in Indonesia. We explore whether and to what degree there is an association of SN diversity with adult health outcomes and investigate potential gender differences, heterogeneous treatment effects, and effect gradients along disablement processes. METHODS: Data came from the fourth and fifth waves of the Indonesian Family Life Survey fielded in 2007-08 and 2014-15. The analytic sample consisted of 3060 adults aged 50+ years. The primary exposure variable was the diversity of respondents' SN at baseline. This was measured through a social network index (SNI), conjoining information about household size together with a range of social ties with whom respondents had active contact across six different types of role relationships. Guided by the disablement process model, a battery of 19 outcomes (8 pathologies, 5 impairments, 4 functional limitations, 2 disabilities) were included into analyses. Evidence for causal effects of SN diversity on health was evaluated using outcome-wide multivariable regression adjustment (RA), propensity score matching (PSM), and instrumental variable (IV) analyses. RESULTS: At baseline, 60% of respondents had a low SNI. Results from the RA and PSM models showed greatest concordance and that among women a diverse SN was positively associated with pulmonary outcomes and upper and lower body functions. Both men and women with a high SNI reported less limitations in performing activities of daily living (ADL) and instrumental ADL (IADL) tasks. A high SNI was negatively associated with C-reactive protein levels in women. The IV analyses yielded positive associations with cognitive functions for both men and women. CONCLUSIONS: Diverse SN confer a wide range of strong and heterogeneous long-term health effects, particularly for older women. In settings with limited formal welfare protection, intervening in the SN of older adults and safeguarding their access to diverse networks can be an investment in population health, with manifold implications for health and public policy.

The Anthropology of Plastics: An Agenda for Local Studies of a Global Matter of Concern.

Anthropology has largely ignored plastics, even as they have emerged as the paradigmatic material-and problem-of our times. In this article, we make the case for an anthropology of plastics as a priority for environmental and medical anthropological research. Drawing from exploratory fieldwork in India, we briefly highlight the benefits and risks of different types of plastics, identify areas for anthropological investigations of human-plastic entanglements, and unpack major debates about plastic control. We recommend analyses that take into account the social life of plastics and the life cycle of plastic production, consumption, circulation, disposal, retrieval, and decomposition. We propose a facilitator role for anthropologists in bringing environmental NGOs and the plastic industry to the table to reduce the human and environmental health risks related to widespread reliance on plastics. Overall, we argue that anthropological analyses are urgently needed to address environmental and global health concerns related to plastics.

Why women choose compounded bioidentical hormone therapy: lessons from a qualitative study of menopausal decision-making.

BACKGROUND: In recent years, compounded bioidentical hormone therapy (CBHT) has emerged as a popular alternative to manufactured, FDA approved hormone therapy (HT)-despite concerns within the medical community and the availability of new FDA approved "bioidentical" products. This study aims to characterize the motivations for using CBHT in a U.S. sample of ordinary midlife women. METHODS: We analyze data collected from 21 current and former users of CBHT who participated in a larger qualitative study of menopausal decision-making among U.S. women. Interviews and focus groups were audio-recorded, transcribed verbatim, and analyzed thematically using an iterative inductive and deductive process. RESULTS: Although women's individual motivations varied, two overarching themes emerged: "push motivations" that drove women away from conventional HT and from alternative therapies, and "pull motivations" that attracted women to CBHT. Push motivations focused on (1) fear and uncertainty about the safety of conventional HT, (2) an aversion to conjugated estrogens in particular, and (3) and overarching distrust of a medical system perceived as dismissive of their concerns and overly reliant on pharmaceuticals. Participants also voiced dissatisfaction with the effectiveness of herbal and soy supplements. Participants were attracted to CBHT because they perceive it to be (1) effective in managing menopausal symptoms, (2) safer than conventional HT, (3) tailored to their individual bodies and needs, and (4) accompanied by enhanced clinical care and attention. CONCLUSIONS: This study finds that women draw upon a range of "push" and "pull" motivations in their decision to use CBHT. Importantly, we find that women are not only seeking alternatives to conventional pharmaceuticals, but alternatives to conventional care where their menopausal experience is solicited, their treatment goals are heard, and they are engaged as agents in managing their own menopause. The significance of this finding goes beyond understanding why women choose CBHT. Women making menopause treatment decisions of all kinds would benefit from greater shared decision-making in the clinical context in which they are explicitly invited to share their experiences, priorities, and preferences. This would also provide an opportunity for clinicians to discuss the pros and cons of conventional HT, CBHT, and other approaches to managing menopause.

Implementation of tobacco cessation brief intervention in complementary and alternative medicine practice: qualitative evaluation.

BACKGROUND: This article presents findings from qualitative interviews conducted as part of a research study that trained Acupuncture, Massage, and Chiropractic practitioners' in Arizona, US, to implement evidence-based tobacco cessation brief interventions (BI) in their routine practice. The qualitative phase of the overall study aimed to assess: the impact of tailored training in evidence-based tobacco cessation BI on complementary and alternative medicine (CAM) practitioners' knowledge and willingness to implement BIs in their routine practice; and their patients' responses to cessation intervention in CAM context. METHODS: To evaluate the implementation of skills learned from a tailored training program, we conducted semi-structured qualitative interviews with 54 CAM practitioners in Southern Arizona and 38 of their patients. Interview questions focused on reactions to the implementation of tobacco cessation BIs in CAM practice. RESULTS: After participating in a tailored BI training, CAM practitioners reported increased confidence, knowledge, and motivation to address tobacco in their routine practice. Patients were open to being approached by CAM practitioners about tobacco use and viewed BIs as an expected part of wellness care. CONCLUSIONS: Tailored training motivated CAM practitioners in this study to implement evidence-based tobacco cessation BIs in their routine practice. Results suggest that CAM practitioners can be a valuable point of contact and should be included in tobacco cessation efforts.

Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain.

In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response.

Comorbidity: Reconsidering the Unit of Analysis.

In this short essay, I wish to briefly discuss smoking, polypharmacy, the human biome and multispecies relations, and biomedicalization as a means of stretching the common ways we think about comorbidity. My intent is to expand our thinking about comorbidity and multimorbidity beyond the individual as a unit of analysis, to reframe comorbidity in relation to trajectories of risk, and to address comorbid states of our own making when the treatment of one health problem results in the experience of additional health problems. I do so as a corrective to what I see as an overly narrow focus on comorbidity as co-occurring illnesses within a single individual, and as a complement to critical medical anthropological assessments of synergistic comorbid conditions (syndemics) occurring in structurally vulnerable populations living in environments of risk exposed to macro and micro pathogenic agents.

The Social Life of Health Insurance in Low- to Middle-income Countries: An Anthropological Research Agenda.

The following article identifies new areas for engaged medical anthropological research on health insurance in low- and middle-income countries (LMICs). Based on a review of the literature and pilot research, we identify gaps in how insurance is understood, administered, used, and abused. We provide a historical overview of insurance as an emerging global health panacea and then offer brief assessments of three high-profile attempts to provide universal health coverage. Considerable research on health insurance in LMICs has been quantitative and focused on a limited set of outcomes. To advance the field, we identify eight productive areas for future ethnographic research that will add depth to our understanding of the social life and impact of health insurance in LMICs. Anthropologists can provide unique insights into shifting health and financial practices that accompany insurance coverage, while documenting insurance programs as they evolve and respond to contingencies.

Is There a Role for Complementary and Alternative Medicine in Preventive and Promotive Health? An Anthropological Assessment in the Context of U.S. Health Reform.

Chronic conditions associated with lifestyle and modifiable behaviors are the leading causes of morbidity and mortality in the United States. The implementation of the Affordable Care Act offers an historic opportunity to consider novel approaches to addressing the nation's public health concerns. We adopt an anticipatory anthropological perspective to consider lifestyle behavior change as common ground shared by practitioners of both biomedicine and common forms of complementary and alternative medicine (CAM). At issue is whether CAM practitioners might play a more proactive and publicly endorsed role in delivering preventive and promotive health services to address these needs. Recognizing that this is a contentious issue, we consider two constructive roles for engaged medical anthropologists: (1) as culture brokers helping to facilitate interprofessional communities of preventive and promotive health practice and (2) in collaboration with health service researchers developing patient-near evaluations of preventive and promotive health services on patient well-being and behavior change.

Printed Educational Materials' Impact on Tobacco Cessation Brief Interventions in CAM Practice: Patient and Practitioner Experiences.

Printed educational materials (PEMs) have long demonstrated their usefulness as economical and effective media for health communication. In this article, we evaluate the impact of targeted tobacco cessation PEMS for use along with a brief intervention training designed for three types of complementary and alternative medicine (CAM) practitioners: chiropractic, acupuncture, and massage. We describe how PEMs in CAM practitioners' offices were perceived and used by practitioners and by patients. Semistructured qualitative interviews were conducted with 53 practitioners and 38 of their patients. This analysis specifically focused on developing and distributing project-related posters and pamphlets in CAM practice. Our findings indicate that materials (1) legitimated tobacco-related expertise among CAM practitioners and tobacco-related conversations as part of routine CAM practice, (2) increased practitioners' willingness to approach the topic of tobacco with patients, (3) created an effective way to communicate tobacco-related information and broaden the reach of brief intervention initiatives, and (4) were given to patients who were not willing to engage in direct discussion of tobacco use with practitioners.

Health insurance in India: what do we know and why is ethnographic research needed.

The percentage of India's national budget allocated to the health sector remains one of the lowest in the world, and healthcare expenditures are largely out-of-pocket (OOP). Currently, efforts are being made to expand health insurance coverage as one means of addressing health disparity and reducing catastrophic health costs. In this review, we document reasons for rising interest in health insurance and summarize the country's history of insurance projects to date. We note that most of these projects focus on in-patient hospital costs, not the larger burden of out-patient costs. We briefly highlight some of the more popular forms that government, private, and community-based insurance schemes have taken and the results of quantitative research conducted to assess their reach and cost-effectiveness. We argue that ethnographic case studies could add much to existing health service and policy research, and provide a better understanding of the life cycle and impact of insurance programs on both insurance holders and healthcare providers. Drawing on preliminary fieldwork in South India and recognizing the need for a broad-based implementation science perspective (studying up, down and sideways), we identify six key topics demanding more in-depth research, among others: (1) public awareness and understanding of insurance; (2) misunderstanding of insurance and how this influences health care utilization; (3) differences in behavior patterns in cash and cashless insurance systems; (4) impact of insurance on quality of care and doctor-patient relations; (5) (mis)trust in health insurance schemes; and (6) health insurance coverage of chronic illnesses, rehabilitation and OOP expenses.

Developing a smoke free homes initiative in Kerala, India.

BACKGROUND: Results of the Global Adult Tobacco Survey in Kerala, India found that 42 % of adults were exposed to second hand smoke (SHS) inside the home. Formative research carried out in rural Kerala suggests that exposure may be much higher. Numerous studies have called for research and intervention on SHS exposure among women and children as an important component of maternal and child health activities. METHODS: Community-based participatory research was carried out in Kerala. First, a survey was conducted to assess prevalence of SHS exposure in households. Next, a proof of concept study was conducted to develop and test the feasibility of a community-wide smoke free homes initiative. Educational materials were developed and pretested in focus groups. After feasibility was established, pilot studies were implemented in two other communities. Post intervention, surveys were conducted as a means of assessing changes in community support. RESULTS: At baseline, between 70 and 80 % of male smokers regularly smoked inside the home. Over 80 % of women had asked their husband not to do so. Most women felt powerless to change their husband's behavior. When women were asked about supporting a smoke free homes intervention, 88 % expressed support for the idea, but many expressed doubt that their husbands would comply. Educational meetings were held to discuss the harms of second hand smoke. Community leaders signed a declaration that their community was part of the smoke free homes initiative. Six months post intervention a survey was conducted in these communities; between 34 and 59 % of men who smoked no longer smoked in their home. CONCLUSIONS: The smoke free homes initiative is based on the principle of collective efficacy. Recognizing the difficulty for individual women to effect change in their household, the movement establishes a smoke free community mandate. Based on evaluation data from two pilot studies, we can project that between a 30 and 60 % reduction of smoking in the home may be achieved, the effect size determined by how well the smoke free home steps are implemented, the characteristics of the community, and the motivation of community level facilitators.

Intervention development for integration of conventional tobacco cessation interventions into routine CAM practice.

BACKGROUND: Practitioners of complementary and alternative medicine (CAM) therapies are an important and growing presence in health care systems worldwide. A central question is whether evidence-based behavior change interventions routinely employed in conventional health care could also be integrated into CAM practice to address public health priorities. Essential for successful integration are intervention approaches deemed acceptable and consistent with practice patterns and treatment approaches of different types of CAM practitioners - that is, they have context validity. Intervention development to ensure context validity was integral to Project CAM Reach (CAMR), a project examining the public health potential of tobacco cessation training for chiropractors, acupuncturists and massage therapists (CAM practitioners). This paper describes formative research conducted to achieve this goal. METHODS: Intervention development, undertaken in three CAM disciplines (chiropractic, acupuncture, massage therapy), consisted of six iterative steps: 1) exploratory key informant interviews; 2) local CAM practitioner community survey; 3) existing tobacco cessation curriculum demonstration with CAM practitioners; 4) adapting/tailoring of existing curriculum; 5) external review of adaptations; 6) delivery of tailored curriculum to CAM practitioners with follow-up curriculum evaluation. RESULTS: CAM practitioners identified barriers and facilitators to addressing tobacco use with patients/clients and saw the relevance and acceptability of the intervention content. The intervention development process was attentive to their real world intervention concerns. Extensive intervention tailoring to the context of each CAM discipline was found unnecessary. Participants and advisors from all CAM disciplines embraced training content, deeming it to have broad relevance and application across the three CAM disciplines. All findings informed the final intervention. CONCLUSIONS: The participatory and iterative formative research process yielded an intervention with context validity in real-world CAM practices as it: 1) is patient/client-centered, emphasizing the practitioner's role in a healing relationship; 2) is responsive to the different contexts of CAM practitioners' work and patient/client relationships; 3) integrates relevant best practices from US Public Health Service Clinical Practice Guidelines on treating tobacco dependence; and 4) is suited to the range of healing philosophies, scopes of practice and practice patterns found in participating CAM practitioners. The full CAMR study to evaluate the impact of the CAMR intervention on CAM practitioners' clinical behavior is underway.

A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies.

BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

Considerations for practice-based research: a cross-sectional survey of chiropractic, acupuncture and massage practices.

BACKGROUND: Complementary and alternative medicine (CAM) use has steadily increased globally over the past two decades and is increasingly playing a role in the healthcare system in the United States. CAM practice-based effectiveness research requires an understanding of the settings in which CAM practitioners provide services. This paper describes and quantifies practice environment characteristics for a cross-sectional sample of doctors of chiropractic (DCs), licensed acupuncturists (LAcs), and licensed massage therapists (LMTs) in the United States. METHODS: Using a cross-sectional telephone survey of DCs (n = 32), LAcs (n = 70), and LMTs (n = 184) in the Tucson, AZ metropolitan area, we collected data about each location where practitioners work, as well as measures on practitioner and practice characteristics including: patient volume, number of locations where practitioners worked, CAM practitioner types working at each location, and business models of practice. RESULTS: The majority of practitioners reported having one practice location (93.8% of DCs, 80% of LAcs and 59.8% of LMTs) where they treat patients. Patient volume/week was related to practitioner type; DCs saw 83.13 (SD = 49.29) patients/week, LAcs saw 22.29 (SD = 16.88) patients/week, and LMTs saw 14.21 (SD =10.25) patients per week. Practitioners completed surveys for N = 388 practice locations. Many CAM practices were found to be multidisciplinary and/or have more than one practitioner: 9/35 (25.7%) chiropractic practices, 24/87 (27.6%) acupuncture practices, and 141/266 (53.0%) massage practices. Practice business models across CAM practitioner types were heterogeneous, e.g. sole proprietor, employee, partner, and independent contractor. CONCLUSIONS: CAM practices vary across and within disciplines in ways that can significantly impact design and implementation of practice-based research. CAM research and intervention programs need to be mindful of the heterogeneity of CAM practices in order to create appropriate interventions, study designs, and implementation plans.

Developing a fully integrated tobacco curriculum in medical colleges in India.

BACKGROUND: This paper describes a pioneering effort to introduce tobacco cessation into India's undergraduate medical college curriculum. This is the first ever attempt to fully integrate tobacco control across all years of medical college in any low and middle income country. The development, pretesting, and piloting of an innovative modular tobacco curriculum are discussed as well as challenges that face implementation and steps taken to address them and to advocate for adoption by the Medical Council of India. METHODS: In-depth interviews were conducted with administrators and faculty in five medical colleges to determine interest in and willingness to fully integrate smoking cessation into the college curriculum. Current curriculum was reviewed for present exposure to information about tobacco and cessation skill training. A modular tobacco curriculum was developed, pretested, modified, piloted, and evaluated by faculty and students. Qualitative research was conducted to identify challenges to future curriculum implementation. RESULTS: Fifteen modules were successfully developed focusing on the public health importance of tobacco control, the relationship between tobacco and specific organ systems, diseases related to smoking and chewing tobacco, and the impact of tobacco on medication effectiveness. Culturally sensitive illness specific cessation training videos were developed. Faculty and students positively evaluated the curriculum as increasing their competency to support cessation during illness as a teachable moment. Students conducted illness centered cessation interviews with patients as a mandated part of their coursework. Systemic challenges to implementing the curriculum were identified and addressed. CONCLUSIONS: A fully integrated tobacco curriculum for medical colleges was piloted in 5 colleges and is now freely available online. The curriculum has been adopted by the state of Kerala as a first step to gaining Medical Council of India review and possible recognition.

Works of Illness and the Challenges of Social Risk and the Specter of Pain in the Lived Experience of TMD.

Temporomandibular Disorders (TMD) represent a particular form of chronic pain that, while not outwardly debilitating, profoundly impacts interactions as fundamental to human existence as smiling, laughing, speaking, eating, and intimacy. Our analysis, informed by an expanded "works of illness" assessment, draws attention to work surrounding social and physical risk. We refer to these as the work of stoicism and the work of vigilance and identify double binds created in contexts that call for both. Conflicting authorial stances in informants' narratives are shown to be essential in maintaining a positive identity in the face of illness. While earlier ethnographic studies report TMD sufferers' experience of stigma and search for diagnosis and legitimacy, we present a group of individuals who have accepted diagnosis at face value and soldier through pain as a fundamental aspect of their identity.