Addressing COVID-19 vaccination equity for Hispanic/Latino communities by attending to aguantarismo: A Californian US-Mexico border perspective.

With an eye to health equity and community engagement in the context of the initial COVID-19 vaccine roll-out, the COVID-19-related concerns of the Latinx (Hispanic/Latino) community in southern San Diego (California, USA) were examined using 42 rapid, ethnographically-informed interviews and two focus groups conducted in early-mid 2021. An anthropologically oriented qualitative analysis delimited the cultural standpoint summarized as aguantarismo, which celebrates human durability in the face of socioeconomic hardship and the capacity to abide daily life's challenges without complaint. After characterizing aguantarismo, its role in both undermining and supporting vaccine uptake is explored. To avoid diverting attention from the structural factors underlying health inequities, the analysis deploys the theoretical framework of critical medical anthropology, highlighting inequities that gain expression in aguantarismo, and the indifference toward vaccination that it can support. In placing critical medical anthropology into conversation with the cultural values approach to public health, the analysis sheds new light on the diversity of human strategies for coping with infectious disease and uncovers new possibilities for effective vaccination promotion. Findings will be useful to public health experts seeking to convert non-vaccinators and optimize booster and pediatric COVID-19 vaccine communications. They will also contribute to the literature on cultural values in relation to Hispanic/Latino or border health more broadly, both by confirming the vital flexibility of cultural standpoints like aguantarismo and by documenting in situ what is to the social science and health literature, albeit not to cultural participants, a novel constellation.

Cultural conformity and cannabis care in the wake of intractable pediatric epilepsy.

Biomedicine controls seizures for many children with epilepsy - but not all. In such cases, parents struggle in the wake of various structural, cultural, and corporeal ruptures. Continued use of ineffective medications can lead, iatrogenically, to frightening and serious symptoms and debilitations whose effects, along with those of uncontrolled seizures, ripple outward in challenging ways. Using data from 25 Californian (US) parents who favored providing cannabis to their ill children to meet the iatrogenic burdens of biomedical epilepsy treatments in 2015, well before cannabis's present destigmatization, this paper explores parental refiguration of the effects of clinical iatrogenesis as inevitable - and as productive of evidence necessary to finding better options. In attending to the generative dimensions of iatrogenesis, this paper strives to help clarify the dilemma for parents who critique biomedicine's isolating, materialist, and sometimes apparently haphazard approach to their children, but depend on biomedical and associated systems for their family's well-being nonetheless. Along the way, this paper underscores raced and gendered dimensions of their experiences. Rather than rejecting biomedicine, most hung on tightly, blaming the uncontrolled seizures and their aftermath on a lag in 'the science' and pointing to the cultural idea that every child is unique in explaining their own children's non-responsiveness to treatment thus far. Likewise, they worked to determine effective cannabis regimens with scientised rigour. However, in the end - and in keeping with a culture of (male) Whiteness - stigmatisation, fatigue from chronic care provision, faith in science, and a need for a biomedically-mediated form of social belonging underwrote a majority desire for cannabis's incorporation into the official biomedical pharmacopeia.

Parent use of cannabis for intractable pediatric epilepsy: Everyday empiricism and the boundaries of scientific medicine.

Cannabis is an increasingly sought-after remedy for US children with intractable (biomedically uncontrollable) epilepsy. However, like other complementary-alternative medicine (CAM) modalities, and particularly as a federally illegal, stigmatized substance, it is unsanctioned by mainstream medicine. Parents are largely on their own when it comes to learning about, procuring, dispensing, and monitoring treatments. Exploring how they manage is crucial to better assist them. Moreover, it can illuminate how 'research' done on the ground by laypeople variously disrupts and reinforces lay-expert and science-non-science divides. To those ends, in 2016, 25 Southern California parents who used, had used, or sought to use cannabis pediatrically for epilepsy/seizures were interviewed regarding their evidentiary standards, research methods, and aims when trying the drug. Parents generally described their work as experimentation; they saw their efforts as adhering to authorized scientific practices and standards, and as contributing to the authorized medical cannabis knowledge base. Findings subverted assumptions, based on an outdated stereotype of CAM, that cannabis-using parents do not believe in biomedicine. Indeed, parents' desire for their children's biomedical demarginalization, combined with biomedical dependency and a high caregiver burden, fueled a collaborative stance. Implications for understanding the boundaries of science are explored, as are norms for parent agency as ill children's care managers, radicalization among people affected by contested illnesses, and the future of 'medical marijuana.'

What is herd immunity, and how does it relate to pediatric vaccination uptake? US parent perspectives.

In light of current concern over pediatric immunization rates, 53 US parents with at least one child kindergarten age or younger were surveyed and interviewed regarding vaccine decision making. Data were collected in 2014 in San Diego, California. Herd immunity was not a salient issue: only six (11.3%) referenced the term or concept spontaneously; others had to be prompted. Parents familiar with herd immunity (70%) variously saw it as not just unnecessary but unproven, illogical, unrealistic, and unreliable. For instance, parents questioned its attainability because many adults do not immunize themselves. Some understood the concept negatively, as an instance of "herd mentality." Further, having knowledge of herd immunity that public health experts would deem 'correct' did not lead to full vaccination. Implications of findings for understanding how the public makes use of scientific information, the potential role of public health messaging regarding altruism and 'free-riding,' and assumptions that vaccine-cautious parents would willfully take advantage of herd immunity are explored in relation to parent role expectations and American individualism.

Information Curation among Vaccine Cautious Parents: Web 2.0, Pinterest Thinking, and Pediatric Vaccination Choice.

To learn about pediatric vaccine decision-making, we surveyed and interviewed US parents with at least one child kindergarten age or younger (N = 53). Through an anthropologically informed content analysis, we found that fully vaccinating parents (n = 33) mostly saw vaccination as routine. In contrast, selective and nonvaccinating parents (n = 20) exhibited the type of self-informed engagement that the health care system recommends. Selective vaccinators also expressed multiple, sometimes contradictory positions on vaccination that were keyed to individual children's biologies, child size, environmental hazards, specific diseases, and discrete vaccines. Rather than logical progressions, viewpoints were presented as assembled collections, reflecting contemporary information filtering and curation practices and the prevalence of collectively experienced and constructed digital "hive" narratives. Findings confirm the need for a noncategorical approach to intervention that accommodates the fluid, polyvalent nature of vaccine reasoning and the curatorial view selectively vaccinating parents take toward information while honoring their efforts at engaged healthcare consumption.

Social Cultivation of Vaccine Refusal and Delay among Waldorf (Steiner) School Parents.

U.S. media reports suggest that vastly disproportionate numbers of un- and under-vaccinated children attend Waldorf (private alternative) schools. After confirming this statistically, I analyzed qualitative and quantitative vaccination-related data provided by parents from a well-established U.S. Waldorf school. In Europe, Waldorf-related non-vaccination is associated with anthroposophy (a worldview foundational to Waldorf education)­but that was not the case here. Nor was simple ignorance to blame: Parents were highly educated and dedicated to self-education regarding child health. They saw vaccination as variously unnecessary, toxic, developmentally inappropriate, and profit driven. Some vaccine caution likely predated matriculation, but notable post-enrollment refusal increases provided evidence of the socially cultivated nature of vaccine refusal in the Waldorf school setting. Vaccine caution was nourished and intensified by an institutionalized emphasis on alternative information and by school community norms lauding vaccine refusal and masking uptake. Implications for intervention are explored.

Salutogenic Education? Movement and Whole Child Health in a Waldorf (Steiner) School.

Waldorf education, an independent alternative to public schooling, aims to produce holistically healthy graduates in a formulation that rejects the conventional distinction between education and health. Also striving to bridge that divide, this article characterizes the pedagogically salutogenic techniques Waldorf teachers use in pre-kindergarten (pre-K) and lower grade classes and explicates the ethnomedical understandings underlying them. Waldorf teachers position children as budding participants in a unified field of spiritual and other forces, prioritizing whole-child activities that keep these forces healthfully motile. Their work entails a critique not only of mainstream public schooling's ostensibly pathogenic "head-to-head" focus, but also of the biomedical approach to pediatric health. My analysis of this conjoined critique takes into account the cultural, structural, and existential realities within which Waldorf education's salutary pedagogy is daily framed and fabricated. Further, it explores the implications for anthropology of attending to movement as a key feature of healthful human experience.

Selling medical travel to US patient-consumers: the cultural appeal of website marketing messages.

More US-based patients than ever are travelling abroad for medical or dental services. Beyond financial incentives, what cultural factors have supported this trend? Because of their interest in selling medical travel, medical travel agencies (MTAs) have vested interests in this question. To find out how they are answering it, an ethnographic content analysis of MTA websites was undertaken. Beyond themes promoting a 'worry-free experience' of 'legitimate services', themes linking healthcare consumerism to culturally specific identity ideals and self-creation/representation processes predominated. Themes relating to the demonstration of social position, savvy expression of good consumer judgment, and achievement of libertarian ideals figured highly. However, various inconsistencies (including an appeal to tourism in some but not other situations) suggested that medical travel involves, for the US-based consumer, a complex act of juggling context-specific self-identity desires and expectations in relation to healthcare. The potential impact of prevailing discourses on 'self-construction-in-practice' was explored. Findings enhance understanding of the care seeking process as experienced within the context of globalized, mass-mediated healthcare consumerism. They also point to the need for finer-grained distinctions than the global gloss 'medical travel' offers.

Satisfaction and use of a spiritually based mantram intervention for childbirth-related fears in couples.

This study assessed patient satisfaction with the use of a spiritually based (mantram/sacred word) intervention in expecting couples. A mixed-methods design, experimental repeated measures with interviews at 6-month follow-up was conducted. Satisfaction was moderate to high. Mantram was used for labor pains and uncertainty. Implications include scheduling flexible classes earlier in pregnancy. A larger randomized study is needed to assess intervention effectiveness.

Medical travel: what it means, why it matters.

Markets for medical travel have grown immensely in the past few years. They have attracted the attention not only of healthcare consumers, providers, and payors but also of scholars from various disciplines. This editorial demonstrates some of the ways that anthropology can contribute to current efforts to better understand medical travel. Such contributions have more than important academic implications. Properly packaged, anthropological work on medical travel can be of great value to policymakers and program planners as they grapple with the changes that geographically and subjectively new patterns of healthcare procurement entail.

Paternal fears of childbirth: a literature review.

To date, most studies on paternal childbirth fears have been exploratory or descriptive, conducted outside of the United States, and focused mainly on White, first-time fathers. Identified fears include harm to the mother or newborn, partner pain, feelings of helplessness, lack of knowledge, and fear of high-risk intervention. Fathers often report that childbirth classes are not helpful and, in some cases, even increase their fears. Some fathers view birth as traumatic, changing their perception of and relationship with their partner. Fathers also voice the need for more information and for reassurance that they are doing the right things for their partner during childbirth. This article summarizes the research findings on paternal childbirth fears and recommends topics for future study.

Behind the scenes in health care improvement: the complex structures and emergent strategies of Implementation Science.

Implementation Science (IS) is a new branch of health services research (HSR) that strives to increase the efficiency and effectiveness of health care quality improvement (QI) efforts. Despite the fact that IS takes a systems approach, building contextual factors into its research designs, the complex systems context of IS itself-and the impact this context has on IS practice-has never been scrutinized. Using individual interviews and participant observation, the research described here characterizes key contextual factors affecting how implementation scientists in one large health care organization approach and conduct their research. Some of the organizational and professional system forces structuring their attitudes and actions were grant-related time lines, administrative burdens, and team turnover. The need for publications also figured highly. While such pressures (and related responses to them) may be rife in most grant-funded health care research settings, IS's particularly marginal position drove these implementation scientists to strategically highlight particular aspects of their work depending on which audience or part of the system they required favor from. Their narratives illuminate the contradictions and contests entailed within and engendered by organizational and professional structures, and the strategies used to negotiate these. They also reveal a great deal about the struggles underwriting disciplinary identity claims in a complex systems context.

Measuring persistence of implementation: QUERI Series.

As more quality improvement programs are implemented to achieve gains in performance, the need to evaluate their lasting effects has become increasingly evident. However, such long-term follow-up evaluations are scarce in healthcare implementation science, being largely relegated to the "need for further research" section of most project write-ups. This article explores the variety of conceptualizations of implementation sustainability, as well as behavioral and organizational factors that influence the maintenance of gains. It highlights the finer points of design considerations and draws on our own experiences with measuring sustainability, framed within the rich theoretical and empirical contributions of others. In addition, recommendations are made for designing sustainability analyses. This article is one in a Series of articles documenting implementation science frameworks and approaches developed by the U.S. Department of Veterans Affairs Quality Enhancement Research Initiative (QUERI).

'A routine thing': clinician strategies for implementing HIV testing for at-risk patients in a busy healthcare organisation (and implications for implementation of other new practice recommendations).

Increasing HIV testing is a necessary step toward control of the disease. Many experts suggest routinely offering HIV testing to specific population segments. We explore provider discourse regarding an HIV test implementation project with the aim of illuminating a structurally emergent clinician strategy for promoting testing and the socio-cultural factors underlying it. Twenty US Veterans Affairs Healthcare System clinical care providers were interviewed. Using standard anthropological text analysis techniques, themes, their relationships, and the significance of these for increasing appropriately targeted HIV test offers were established. Presenting the HIV test offer to their patients as if routine ('routinisation') supported providers' desire to do no harm by lessening the test's potential stigma. Offering the test helped providers maintain professional integrity: it empowered veterans to realise access to care and fit with providers' sense of honour and duty. Routinising HIV testing also helped providers to manage scarce time effectively. Findings can be leveraged to support routine screening's successful roll-out. The carefully managed introduction of routine HIV test offering policies will formalise and legitimise productive strategies of destigmatisation already being enacted by some front-line providers. The fact that routinisation strategies are in use although HIV testing is not actually routine attests to the potential power routinisation has to reduce HIV's stigma, increase HIV test uptake, and thereby improve access to care. What I've learned about tough questions is: The more routine you make them, the easier it is to get the questions answered, the less destructive it is to the relationship and that's the sort of paradigm I've come to believe in and will use now into the future. (Marvin K, MD).

Canine visitation (pet) therapy: pilot data on decreases in child pain perception.

PURPOSE: To explore the effectiveness of canine visitation therapy (CVT) in pediatric pain management in a tertiary care children's hospital, a descriptive pilot study was conducted. METHOD: A convenience sample of 25 English-speaking children ages 5 to 18 years who underwent surgery and experienced acute postoperative pain participated in a standard, one-time CVT intervention. Each child completed a pre-post survey and a post intervention interview. FINDINGS: Quantitative pre-post findings indicate that CVT significantly reduced perceived pain. Qualitative findings suggest that one mechanism that makes CVT effective may be cognitive. That is, CVTdistracts children from pain-related cognition and possibly activates comforting thoughts regarding companionship or home. CONCLUSION: The study findings suggest that CVT may be a useful adjunct to traditional pain management for children. IMPLICATIONS: Nurses may better serve their patients when CVT is an option.

Parent-identified barriers to pediatric health care: a process-oriented model.

OBJECTIVE: To further understand barriers to care as experienced by health care consumers, and to demonstrate the importance of conjoining qualitative and quantitative health services research. DATA SOURCES: Transcripts from focus groups conducted in San Diego with English- and Spanish-speaking parents of children with special health care needs. STUDY DESIGN: Participants were asked about the barriers to care they had experienced or perceived, and their strategies for overcoming these barriers. Using elementary anthropological discourse analysis techniques, a process-based conceptual model of the parent experience was devised. PRINCIPAL FINDINGS: The analysis revealed a parent-motivated model of barriers to care that enriched our understanding of quantitative findings regarding the population from which the focus group sample was drawn. Parent-identified barriers were grouped into the following six temporally and spatially sequenced categories: necessary skills and prerequisites for gaining access to the system; realizing access once it is gained; front office experiences; interactions with physicians; system arbitrariness and fragmentation; outcomes that affect future interaction with the system. Key to the successful navigation of the system was parents' functional biomedical acculturation; this construct likens the biomedical health services system to a cultural system within which all parents/patients must learn to function competently. CONCLUSIONS: Qualitative analysis of focus group data enabled a deeper understanding of barriers to care--one that went beyond the traditional association of marker variables with poor outcomes ("what") to reveal an understanding of the processes by which parents experience the health care system ("how,""why") and by which disparities may arise. Development of such process-oriented models furthers the provision of patient-centered care and the creation of interventions, programs, and curricula to enhance such care. Qualitative discourse analysis, for example using this project's widely applicable protocol for generating experientially based models, can enhance our knowledge of the parent/patient experience and aid in the development of more powerful conceptualizations of key health care constructs.

Parents' perceptions of pediatric day surgery risks: unforeseeable complications, or avoidable mistakes?

A decline in people's trust of the US health care system has been documented. But do parents of pediatric patients have specific safety worries? If so, what are they? And what cultural factors inform them? To help answer these questions, in San Diego 35 English- and Spanish-speaking parents' (or guardians') self-reports of perceptions of their child's risk for experiencing a medical error during day surgery were collected using open-ended rapid assessment interviews, and analyzed using qualitative content analysis methods. (The innovative data collection and analysis protocol is described so as to be easily replicable in other settings for other types of highly focused quality improvement initiatives that rely on the inclusion of parent or patient perspectives and entail limited time and resources). Twelve key themes were identified. Anthropological discourse analysis techniques (modified for rapid use with rapidly collected interview data) were then applied to the transcripts in order to generate ideas regarding cultural factors underlying the themes. Discursive patterns of risk rationalization or refutation related to cultural expectations for parenting, children's bodies, and health care consumerism were found. Neither the (careful, loving, good) parent nor the (wisely chosen or well-reputed) care team was to blame for medical errors. Errors were cast as the inevitable results of latent, unanticipatable vulnerabilities inherent in the (defenseless) children undergoing surgery. The anxiety-generating potential of the surgical consent process also was noted. The implications of the findings for action as well as for theories of risk and vulnerability and of childhood and parenthood are discussed.

Between 'desperation' and disability rights: a narrative analysis of complementary/alternative medicine use by parents for children with Down syndrome.

This paper presents a narrative analysis of complementary/alternative medicine (CAM) use by parents for children with Down syndrome (DS), based on interviews conducted with thirty families. Critics often presume that CAM use for children with developmental disabilities reflects parental desperation in the face of limited biomedical options. Integrating insights from anthropological studies of CAM with narrative analyses in disability studies, we constructively complicate this interpretation in two ways. First, we suggest that the appeal of CAM may lie in its discursive consonance with the broader narrative strategies through which parents construct alternatives to conventional definitions of DS as a condition with a fixed, universal, and essentially pathological course. Second, we submit that the process of seeking and evaluating information about CAM is consonant with how parents construct their identities as 'good' parents through describing their roles as committed advocates and service coordinators for their children. In these ways, CAM can be conceptualized as a new discursive resource that parents engage in their culturally and historically specific efforts to articulate the essential human rights of their children, and to assert the moral soundness of their own parenthood. These findings provide a new conceptualization of parents' motives for choosing CAM, thereby posing new questions for further research about CAM use for developmental disabilities.

Communicating with pediatricians about complementary/alternative medicine: perspectives from parents of children with down syndrome.

OBJECTIVES: Barriers to communication about complementary/alternative medicine (CAM) between parents and pediatricians are frequently documented, yet the scope of these barriers remains poorly understood. Such barriers are especially troubling when they involve children with special health needs, among whom CAM use is especially common. This pilot study of parents of children with Down syndrome (DS) used qualitative methods to explore parents' perceptions of the extent and quality of communication about CAM with pediatricians, to elicit parents' recommendations for improvement, and to formulate new research questions. DESIGN: Semistructured interviews were conducted with parents from 30 families with children with DS. Data were audiotaped and analyzed with assistance from qualitative data analysis software. RESULTS: Parents described how they advocated vigorously with their pediatricians about biomedical concerns such as the American Academy of Pediatrics healthcare guidelines for DS, but often avoided discussion of nonbiomedical concerns such as CAM. Many parents looked to pediatricians to initiate conversations about CAM. DISCUSSION: Even parents who assertively advocate for biomedical concerns in their children's health care may be unlikely to disclose and discuss CAM use with their pediatricians. Attending to parents' experiences helps to illuminate the nature and scope of current communication barriers and poses new research questions for assessing and improving parent-physician collaboration about health-related issues that may be prioritized differently by parents and pediatricians.

Good communication in pediatric cancer care: a culturally-informed research agenda.

Communication affects people's factual understanding of the situations they are in. This in turn affects consent to be treated and adherence. Although a growing body of literature concerns cancer communication, it generally concerns adult patients; pediatric-specific knowledge is limited. Furthermore, most research focuses shortsightedly on physicians rather than providers who have more patient contact, favors studying the single visit instead of encompassing the cycle of cancer care, does not take the child into account, and ignores the importance of provider-provider communication. Moreover, cultural issues are only narrowly conceived. In exploring culture's role in pediatric cancer care communication, this article demonstrates that culture cannot be defined as just ethnicity or race. Professions also have cultures and resultant differences in communication patterns that can lead to communication failures. It also shows that there is a crucial need for more applied research as well as more qualitative research that can enrich our understanding of the complicated context-related factors facilitating or barring successful pediatric cancer communication.