The Lancet Series on Syndemics (2017) published March 2, 2017.
A syndemics framework examines the health consequences of identifiable disease interactions and the social, environmental, or economic factors that promote such interaction and worsen disease. This Series introduces the syndemics approach, explains important contrasts with conventional approaches to public health and health-care delivery based on the concept of multimorbidity, and explores how syndemics can be used to tackle health inequities in a comprehensive manner.
Mendenhall, Emily, *Rebecca Rinehart, Christine Musyimi, *Edna Bosire, Victoria Mutiso, and David Ndetei. “An Ethnopsychology of Idioms of Distress in Urban Kenya.” Transcultural Psychiatry, epub Jan 23.
Idioms of distress have become a central construct of anthropologists who aspire to understand the languages that individuals of certain sociocultural groups use to express suffering, pain, or illness. Yet, such idioms are never removed from global flows of ideas within biomedicine that influence how cultural idioms are conceived, understood, and expressed. This article proposes a preliminary model of ethnopsychology described by urban Kenyans, which incorporates local (traditional) and global (biomedical) idioms of distress that are both distinct and overlapping in symptomology and experience. This ethnopsychology was generated from analyzing 100 life history narrative interviews among patients seeking care in a public hospital in Nairobi, Kenya, which explicitly probed into how people experienced and expressed the Kiswahili idioms huzuni (roughly translated as sadness or grief) and dhiki (stress or agony) and English terms stress and depression. Kufikiria sana, or "thinking too much", emerged organically as a powerful cultural idiom and as a symptom or sign of other forms of psychological distress. We propose a preliminary model of ethnopsychology that: 1) highlights social and political factors in driving people to express and experience idioms of distress; 2) reveals how the English terms "stress" and "depression" have been adopted into Kiswahili discourse and potentially have taken on new meaning; 3) suggests that the role of rumination in how people express distress, with increasing severity, is closely linked to the concept of "thinking too much", and; 4) emphasizes how somatization is central to how people think about psychological suffering.
Mendenhall, Emily, Andrew Wooyoung Kim. How to Fail a Scale: Reflections on a Failed Attempt to Assess Resilience.
How we interpret concepts from suffering to survival has been historically debated in the field of anthropology, transcultural psychiatry, and global mental health. These debates have centered on the notion that such concepts are cross-culturally reproducible, although scholars who work the boundaries of culture, medicine, and psychiatry often triangulate methods from internationally standardized scales to various interpretive methods from participant observation to narrative. This article considers resilience, as opposed to suffering, as the subject of a reproducible entity by discussing the failure of an attempt to capture resilience via an internationally reputed scale called the "Resilience Scale for Adults" among cancer patients in urban South Africa. Our effort to utilize the internationally validated scale, and our attempt to draw on ethnographic and interview work to translate this scale to a locally relevant entity failed due to linguistic, cultural, and practical issues. In brief, the attempt failed because our resilience scale was too long, syntactically ambiguous, and culturally inappropriate. We write this article to spur a larger conversation about evaluating resilience from scale to ethnography, and how the concept and measurement of resilience might figure into fields of anthropology and medicine.
McMurry, H. Stowe, Emily Mendenhall, Aravind LR, Lavanya Nambiar, Srinath Satyanarayana, Roopa Shivashankar. 2019. “Co-prevalence of type 2 diabetes mellitus and tuberculosis in low- and middle-income countries: A systematic review.” Diabetes/Metabolism Research and Reviews, 35(1):e3066.
Increasing coprevalence of diabetes mellitus (DM) and tuberculosis (TB) in low-income and middle-income countries (LMICs) indicates a rising threat to the decades of progress made against TB and requires global attention. This systematic review provides a summary of type 2 diabetes and tuberculosis coprevalence in various LMICs. We searched PubMed, Ovid Medline, Embase, and PsychINFO databases for studies that provided estimates of TB-DM coprevalence in LMICs published between 1990 and 2016. Studies that were non-English and exclusively conducted in multidrug resistant-tuberculosis or type 1 diabetes and inpatient settings were excluded. We reviewed 84 studies from 31 countries. There were huge diversity of study designs and diagnostic methods used to estimate coprevalence, and this precluded pooling of the results. Most studies (n = 78) were from small, localized settings. The DM prevalence among TB patients in various LMICs varied from 1.8% to 45%, with the majority (n = 44) between 10% and 30%. The TB prevalence among people with DM ranged from 0.1% to 6.0% with most studies (n = 9) reporting prevalences less than 2%. Coprevalence of TB-DM was higher than general population prevalence of either diseases in these countries. This study underscores the need for intervention and more focused research on TB DM bidirectional screening programs in low-income and middle-income countries as well as integrated chronic disease management.
Wenham, Clare, Rebecca Katz, Charles Birungi, Lisa Boden, Mark Eccleston-Turner, Lawrence O. Gostin, Renzo Guinto, Mark Hellowell, Kristine Husoy Onarheim, Joshua Hutton, Anuj Kapilashrami, Emily Mendenhall, Alexandra Phelan, Marlee Tichenor, Devi Sridhar. 2019. “Global Health Security and Universal Health Coverage: From a Marriage of Convenience to a Strategic, Effective Partnership.” BMJ Global Health, 4(1): e001145.
Global health security and universal health coverage have been frequently considered as "two sides of the same coin". Yet, greater analysis is required as to whether and where these two ideals converge, and what important differences exist. A consequence of ignoring their individual characteristics is to distort global and local health priorities in an effort to streamline policymaking and funding activities. This paper examines the areas of convergence and divergence between global health security and universal health coverage, both conceptually and empirically. We consider analytical concepts of risk and human rights as fundamental to both goals, but also identify differences in priorities between the two ideals. We support the argument that the process of health system strengthening provides the most promising mechanism of benefiting both goals.
Carruth, Lauren, and Emily Mendenhall. “Social Etiologies of Type 2 Diabetes: Crisis and Displacement.” BMJ 361:k1795.
*Bosire, Edna, Emily Mendenhall, Gregory Omondi, David Ndetei. “When Diabetes Confronts HIV: Biological Sub-Citizenship at a Public Hospital in Nairobi, Kenya.” Medical Anthropology Quarterly, epub Aug 16. doi: 10.1111/maq.12476.
This article investigates how international donor policies cultivate a form of biological sub‐citizenship for those with diabetes in Kenya. We interviewed 100 patients at a public hospital clinic in Nairobi, half with a diabetes diagnosis. We focus on three vignettes that illustrate how our study participants differentially perceived and experienced living with and seeking treatment and care for diabetes compared to other conditions, with a special focus on HIV. We argue that biological sub‐citizenship, where those with HIV have consistent and comprehensive free medical care and those with diabetes must pay out‐of‐pocket for testing and treatment, impedes diabetes testing and treatment. Once diagnosed, many are then systematically excluded from the health care system due to their own inability to pay. We argue that the systematic exclusion from international donor money creates a form of biological sub‐citizenship based on neoliberal economic policies that undermine other public health protections, such as universal primary health care.
Mendenhall, Emily. 2017. “Syndemics: A New Path for Global Health Research.” The Lancet, 389: 391.
Tsai, Alexander, Emily Mendenhall, James Trostle, and Ichiro Kawachi. 2017. “Co-occurring epidemics, syndemics, and population health.” The Lancet, 978–82.
Mendenhall, Emily. 2017. “The Georgetown Conference on Global Mental Health: Transdisciplinary Perspectives.” Global Public Health, 13(9):1145-1151.
Mendenhall, Emily, Brandon Kohrt, Shane Norris, David Ndetei, and Dorairaj Prabhakaran. 2017. “Non-communicable Disease Syndemics: Poverty, Depression, and Diabetes among the Urban Poor.” The Lancet, 389: 952-963.
The co-occurrence of health burdens in transitioning populations, particularly in specific socioeconomic and cultural contexts, calls for conceptual frameworks to improve understanding of risk factors, so as to better design and implement prevention and intervention programmes to address comorbidities. The concept of a syndemic, developed by medical anthropologists, provides such a framework for preventing and treating comorbidities. The term syndemic refers to synergistic health problems that affect the health of a population within the context of persistent social and economic inequalities. Until now, syndemic theory has been applied to comorbid health problems in poor immigrant communities in high-income countries with limited translation, and in low-income or middle-income countries. In this Series paper, we examine the application of syndemic theory to comorbidities and multimorbidities in low-income and middle-income countries. We employ diabetes as an exemplar and discuss its comorbidity with HIV in Kenya, tuberculosis in India, and depression in South Africa. Using a model of syndemics that addresses transactional pathophysiology, socioeconomic conditions, health system structures, and cultural context, we illustrate the different syndemics across these countries and the potential benefit of syndemic care to patients. We conclude with recommendations for research and systems of care to address syndemics in low-income and middle-income country settings.
Singer, Merrill, Bayla Ostrach, and Nicola Bulled, and Emily Mendenhall. 2017. “Syndemics and the Biosocial Conception of Health.” The Lancet, 941–50.
The syndemics model of health focuses on the biosocial complex, which consists of interacting, co-present, or sequential diseases and the social and environmental factors that promote and enhance the negative effects of disease interaction. This emergent approach to health conception and clinical practice reconfigures conventional historical understanding of diseases as distinct entities in nature, separate from other diseases and independent of the social contexts in which they are found. Rather, all of these factors tend to interact synergistically in various and consequential ways, having a substantial impact on the health of individuals and whole populations. Specifically, a syndemics approach examines why certain diseases cluster (ie, multiple diseases affecting individuals and groups); the pathways through which they interact biologically in individuals and within populations, and thereby multiply their overall disease burden, and the ways in which social environments, especially conditions of social inequality and injustice, contribute to disease clustering and interaction as well as to vulnerability. In this Series, the contributions of the syndemics approach for understanding both interacting chronic diseases in social context, and the implications of a syndemics orientation to the issue of health rights, are examined.
*McMurry, H. Stowe, Roopa Shivashankar, Emily Mendenhall, and Dorairaj Prabhakaran. 2017. “Today’s risk factors, tomorrow’s disease; overweight and obesity insights from India’s fourth National Family Health Survey.” Economic and Political Weekly (EPW).
India is in the midst of an epidemiological transition, whereby poverty-linked infectious, maternal and nutritional diseases exist in conjunction with non-communicable chronic illnesses. This transition is driven by rapid economic development within which people eat, move, work, and live differently than before. This analysis of the third and fourth rounds of the National Family Health Survey demonstrates that non-communicable diseases, and their risk factors are undergoing a reversal of the social gradient and are moving down the socio-economic ladder into lower-income populations.
Kohrt, Brandon A., Emily Mendenhall, and Peter J. Brown. 2016.“How Anthropological Theory and Methods Can Advance Global Mental Health.” Lancet Psychiatry, 3(May):396-397.
Mendenhall, Emily, Kristin Yarris and Brandon Kohrt. 2016.“Utilization of standardized mental health assessments in anthropological research: possibilities and pitfalls.” Culture, Medicine, and Psychiatry, 40(4):726-745.
In the past decade anthropologists working the boundary of culture, medicine, and psychiatry have drawn from ethnographic and epidemiological methods to interdigitate data and provide more depth in understanding critical health problems. But rarely do these studies incorporate psychiatric inventories with ethnographic analysis. This article shows how triangulation of research methods strengthens scholars’ ability (1) to draw conclusions from smaller data sets and facilitate comparisons of what suffering means across contexts; (2) to unpack the complexities of ethnographic and narrative data by way of interdigitating narratives with standardized evaluations of psychological distress; and (3) to enhance the translatability of narrative data to interventionists and to make anthropological research more accessible to policymakers. The crux of this argument is based on two discrete case studies, one community sample of Nicaraguan grandmothers in urban Nicaragua, and another clinic-based study of Mexican immigrant women in urban United States, which represent different populations, methodologies, and instruments. Yet, both authors critically examine narrative data and then use the Center for Epidemiologic Studies Depression Scale to further unpack meaning of psychological suffering by analyzing symptomatology. Such integrative methodologies illustrate how incorporating results from standardized mental health assessments can corroborate meaning-making in anthropology while advancing anthropological contributions to mental health treatment and policy.
Mendenhall, Emily, Gitonga Isaiah, *Bernadette Nelson, Abednego Musau, Adam D. Koon, Lahra Smith, Victoria Mutiso, David Ndetei. 2016. “Nurses’ Perceptions of mental healthcare in primary-care settings in Kenya.” Global Public Health, 13(4):442-455.
Kenya maintains an extraordinary treatment gap for mental health services because the need for and availability of mental health services are extraordinarily misaligned. One way to narrow the treatment gap is task-sharing, where specialists rationally distribute tasks across the health system, with many responsibilities falling upon frontline health workers, including nurses. Yet, little is known about how nurses perceive task-sharing mental health services. This article investigates nurses’ perceptions of mental healthcare delivery within primary-care settings in Kenya. We conducted a cross-sectional study of 60 nurses from a public urban (n = 20), private urban (n = 20), and public rural (n = 20) hospitals. Nurses participated in a one-hour interview about their perceptions of mental healthcare delivery. Nurses viewed mental health services as a priority and believed integrating it into a basic package of primary care would protect it from competing health priorities, financial barriers, stigma, and social problems. Many nurses believed that integrating mental healthcare into primary care was acceptable and feasible, but low levels of knowledge of healthcare providers, especially in rural areas, and few specialists, would be barriers. These data underscore the need for task-sharing mental health services into existing primary healthcare in Kenya.
Mendenhall, Emily, *H. Stowe McMurry, Roopa Shivashankar, K.M. Venkat Narayan, Nikhil Tandon, Dorairaj Prabhakaran. 2016. “Normalizing Diabetes in Delhi: A Qualitative Study of Health and Healthcare.” Anthropology and Medicine, epub June 21.
The Type 2 diabetes epidemic in India poses challenges to the health system. Yet, little is known about how urban Indians view treatment and self-care. Such views are important within the pluralistic healthcare landscape of India, bringing together allopathic and non-allopathic (or traditional) paradigms and practices. We used in-depth qualitative interviews to examine how people living with diabetes in India selectively engage with allopathic and non-allopathic Indian care paradigms. We propose a ‘discourse marketplace’ model that demonstrates competing ways in which people frame diabetes care-seeking in India’s medical pluralism, which includes allopathic and traditional systems of care. Four major domains emerged from grounded theory analysis: 1) normalization of diabetes in social interactions; 2) stigma; 3) stress; and 4) decision-making with regard to diabetes treatment. We found that participants selectively engaged with aspects of allopathic and non-allopathic Indian illness paradigms to build personalized illness meanings and care plans that served psychological, physical, and social needs. Participants constructed illness narratives that emphasized the social-communal experience of diabetes and as a result, reported less stigma and stress due to diabetes. These data suggest that the pro-social construction of diabetes in India is both helpful and harmful for patients – it provides psychological comfort, but also lessens the impetus for prevention and self-care. Clarifying the social constructions of diabetes and chronic disease in India and other medically pluralistic contexts is a crucial first step to designing locally situated treatment schemes.
Koon, Adam, Lahra Smith, Victoria Mutiso, David Ndetei, and Emily Mendenhall. 2016. “Nurses’ perceptions of universal health coverage and its implications for the Kenyan health sector.”Critical Public Health, 27 (1), 28-38.
Universal health coverage, comprehensive access to affordable and quality health services, is a key component of the newly adopted 2015 Sustainable Development Goals. Prior to the UN resolution, several countries began incorporating elements of universal health coverage into their domestic policy arenas. In 2013, the newly elected President of Kenya announced initiatives aimed at moving towards universal health coverage, which have proven to be controversial. Little is known about how frontline workers, increasingly politically active and responsible for executing these mandates, view these changes. To understand more about how actors make sense of universal health coverage policies, we conducted an interpretive policy analysis using well-established methods from critical policy studies. This study utilized in-depth semi-structured interviews from a cross section of 60 nurses in three health facilities (public and private) in Kenya. Nurses were found to be largely unfamiliar with universal health coverage and interpreted it in myriad ways. One policy in particular, free maternal health care, was interpreted positively in theory and negatively in practice. Nurses often relied on symbolic language to express powerlessness in the wake of significant health systems reform. Study participants linked many of these frustrations to disorganization in the health sector as well as the changing political landscape in Kenya. These interpretations provide insight into charged policy positions held by frontline workers that threaten to interrupt service delivery and undermine the movement towards universal health coverage in Kenya.
Panda, Rajmohan, Swati Srivastava, Divya Persai, Emily Mendenhall, Monika Arora, and Manu Raj Mathur. 2016. “System level approaches for mainstreaming tobacco control into existing health programs in India: Perspectives from the field.” Journal of Family Medicine and Primary Care, 4(4):559-65.
Introduction: India is the second largest consumer of tobacco in the world, and varieties of both smoked and smokeless tobacco products are widely available. The national program for tobacco control is run like a vertical stand-alone program. There is a lack of understanding of existing opportunities and barriers within the health programs that influence the integration of tobacco control messages into them. The present formative research identifies such opportunities and barriers. Methods: We conducted a multi-step, mixed methodological study of primary care personnel and policy-makers in two Indian states of Andhra Pradesh and Gujarat. The primary purpose of our study was to investigate health worker and policy-maker perceptions on the integration of tobacco control intervention. We systematically collected data in three steps: In Step I, we conducted in-depth interviews (IDIs) and focus group discussions with primary care health personnel, Step II consists of a quantitative survey among health care providers (n = 1457) to test knowledge, attitudes and practices in tobacco control and Step III we conducted 75 IDIs with program heads and policy-makers to evaluate the relative congruence of their views on integration of the tobacco control program. Results: Majority of the health care providers recognized tobacco use as a major health problem. There was a general consensus for the need of training for effective dissemination of information from health care providers to patients. Almost 92% of the respondents opined that integration of tobacco control with other health programs will be highly effective to downscale the tobacco epidemic. Conclusions: Our findings suggest the need for integration of tobacco control program into existing health programs. Integration of tobacco control strategies into the health care system within primary and secondary care will be more effective and counseling for tobacco cessation should be available for population at large.
Mendenhall, Emily. 2015. “Syndemic Suffering in Soweto: Violence and Inequality at the Nexus of Health Transition in South Africa.” Annals of Anthropological Practice 38(2): 302-318.
This article examines the roles of structural and interpersonal violence in individual experiences of health transition in South Africa, focusing on women’s narratives of distress and diabetes as well as epidemiology. Over the past decade marked increases in noncommunicable diseases, including type 2 diabetes, have transitioned in South Africa to afflict those who concurrently face great mental health burdens and the world’s largest HIV and AIDS and tuberculosis epidemics. First, this article considers how social and health problems cluster among impoverished populations through a discussion of syndemics theory. Drawing from the VIDDA Syndemic employed to describe the experience of Mexican immigrant women living with diabetes and depression in urban United States, this analysis demonstrates how violence plays a unique role as a perpetuator of suffering through structural, social, psychological, and even biological pathways. Second, data around stress and structural violence, gun violence, and gender‐based violence that emerged from a small study of urban South African women with type 2 diabetes are presented to discuss how violence functions as a cofactor of the syndemic of diabetes and depression in this context. This analysis emphasizes the role of historical and social contexts in how conditions such as depression and diabetes are distributed epidemiologically and experienced individually. Finally, this article argues that the utility of understanding the role of violence in health transition may be a fundamental source of intervention to mitigate the effects of the double burden of diseases on socially and economically marginalized populations in middle‐income countries such as South Africa.
Mendenhall, Emily. 2016. “Beyond Co-Morbidity: A Critical Anthropological Perspective of Depression and Diabetes in Cross-Cultural Contexts.” Medical Anthropology Quarterly, 30(4):462-478.
This article examines the comorbidity concept in medical anthropology. I argue that the dearth of articles on comorbidity in medical anthropology may result from the rise of syndemic theory. Syndemics recognize how social realities shape individual illness experiences as well as distribution of diseases across populations. I discuss synergistic interactions foundational to the syndemics construct through my research of depression and diabetes comorbidity in vulnerable populations from urban United States, India, and South Africa. I argue that social and economic factors that cluster with depression and diabetes alone and together exemplify the biosocial processes that are at the heart of syndemics. In doing so, I illustrate how social, cultural, and economic factors shape individual‐level experiences of co‐occurring diseases despite similar population‐level trends. Finally, I discuss the relevance of syndemics for the fields of medicine and public health while cautioning what must not be lost in translation across disciplines.
Mendenhall, Emily, and Shane A. Norris. 2015. “Diabetes care among urban women in Soweto, South Africa: a qualitative study.” BMC Public Health, 15: 1300. (7 pages)
Escalation of non-communicable diseases such as Type 2 diabetes among low-income populations in low- and middle-income countries presents challenges for health systems. Yet, very little is known about low-income people’s diabetes care experiences in such contexts. One of the greatest challenges of diabetes care in such contexts is providing care for those who face poverty, poor healthcare access, and concurrent physical and mental conditions. This article investigates women’s experiences with diabetes care in Soweto, a township of Johannesburg, South Africa.
Mendenhall, Emily, Gregory Omondi, *Edna Bosire, Gitonga Isaiah, Abednego Musau, David Ndetei, Victoria Mutiso. 2015. “Stress, Diabetes, and Infection: Syndemic Suffering at an Urban Kenyan Hospital.” Social Science and Medicine, 146: 11-20.
The complexity of sickness among Kenya’s urban poor cannot be dissociated from how social and health problems become syndemic. Increasingly diabetes and other non-communicable diseases (NCDs) are emerging among low-income populations that also are most afflicted by social stress and infection. This article examines how social stress, psychological distress, and physical illness among patients in a public hospital in Nairobi, Kenya, produce syndemic suffering, defined by lived experiences of syndemic clustering such as diabetes with depression and infection. We recruited 100 urban public hospital patients, of which half were women, and half had type 2 diabetes from June to August 2014. We administered written informed consent and collected anthropometrics and blood samples before we conducted lengthy mixed qualitative and survey interviews. We analyzed social stress in narrative interviews using content analysis and evaluated social and physical contributors to mental distress with frequency tables and logistic regression. We found that people experienced diabetes through a complex social and medical framework, where social problems were cause and consequence to psychological and physical suffering. Women’s narratives revealed more social suffering as well as more mental distress and somatic symptoms, including multi-morbidities, than men’s. People with diabetes reported not only concurrent anxiety and depression but also common infections, including malaria, tuberculosis, and HIV/AIDS. Narratives reveal how NCDs concurrent with infections, and HIV in particular, produce financial challenges for patients, especially when HIV treatment is free and patients must pay out-of-pocket for diabetes care. Future studies should investigate syndemic clustering of infections and NCDs among low-income populations at the population-level.
Mendenhall, Emily, and Shane A. Norris. 2015. “When HIV is Ordinary, Diabetes New: Remaking Suffering in a South African Township.” Global Public Health, 10(4): 449-62
Escalation of non-communicable diseases (NCDs) among urban South African populations disproportionately afflicted by HIV/AIDS presents not only medical challenges but also new ways in which people understand and experience sickness. In Soweto, the psychological imprints of political violence of the Apartheid era and structural violence of HIV/AIDS have shaped social and health discourses. Yet, as NCDs increasingly become part of social and biomedical discussions in South African townships, new frames for elucidating sickness are emerging. This article employs the concept of syndemic suffering to critically examine how 27 women living with Type 2 diabetes in Soweto, a township adjacent to Johannesburg known for socio-economic mobility as well as inequality, experience and understand syndemic social and health problems. For example, women described how reconstructing families and raising grandchildren after losing children to AIDS was not only socially challenging but also affected how they ate, and how they accepted and managed their diabetes. Although previously diagnosed with diabetes, women illustrated how a myriad of social and health concerns shaped sickness. Many related diabetes treatment to shared AIDS nosologies, referring to diabetes as ‘the same’ or ‘worse’. These narratives demonstrate how suffering weaves a social history where HIV becomes ordinary, and diabetes new.
Mendenhall, Emily, Mary J. De Silva, Charlotte Hanlon, Inge Petersen, Rahul Shidhaye, Mark Jordans, Nagendra Luitel, Joshua Ssebunnya, Abebaw Fekadu, Vikram Patel, Mark Tomlinson, Crick Lund. 2014. “Acceptability and feasibility of using non-specialist health workers to deliver mental health care: stakeholder perceptions from the PRIME district sites in Ethiopia, India, Nepal, South Africa, and Uganda.” Social Science and Medicine 118: 33-42.
Three-quarters of the global mental health burden exists in low- and middle-income countries (LMICs), yet the lack of mental health services in resource-poor settings is striking. Task-sharing (also, task-shifting), where mental health care is provided by non-specialists, has been proposed to improve access to mental health care in LMICs. This multi-site qualitative study investigates the acceptability and feasibility of task-sharing mental health care in LMICs by examining perceptions of primary care service providers (physicians, nurses, and community health workers), community members, and service users in one district in each of the five countries participating in the PRogramme for Improving Mental health carE (PRIME): Ethiopia, India, Nepal, South Africa, and Uganda. Thirty-six focus group discussions and 164 in-depth interviews were conducted at the pre-implementation stage between February and October 2012 with the objective of developing district level plans to integrate mental health care into primary care. Perceptions of the acceptability and feasibility of task-sharing were evaluated first at the district level in each country through open-coding and then at the cross-country level through a secondary analysis of emergent themes. We found that task-sharing mental health services is perceived to be acceptable and feasible in these LMICs as long as key conditions are met: 1) increased numbers of human resources and better access to medications; 2) ongoing structured supportive supervision at the community and primary care-levels; and 3) adequate training and compensation for health workers involved in task-sharing. Taking into account the socio-cultural context is fundamental for identifying local personnel who can assist in detection of mental illness and facilitate treatment and care as well as training, supervision, and service delivery. By recognizing the systemic challenges and sociocultural nuances that may influence task-sharing mental health care, locally-situated interventions could be more easily planned to provide appropriate and acceptable mental health care in LMICs.
Weaver, Lesley Jo, and Emily Mendenhall. 2014. “Applying Syndemics and Chronicity: Interpretations from Studies of Poverty, Depression, and Diabetes.” Medical Anthropology: Cross-Cultural Studies in Health and Illness 33(2): 1-17. Authors contributed equally
Medical anthropologists working with global health agendas must develop transdisciplinary frameworks to communicate their work. This article explores two similar but underutilized theoretical frameworks in medical anthropology, and discusses how they facilitate new insights about the relationships between epidemiological patterns and individual-level illness experiences. Two cases from our fieldwork in New Delhi and Chicago are presented to illustrate how syndemics and chronicity theories explain the epidemic problems of co-occurring depression and type 2 diabetes. We use these case studies to illustrate how the holistic agendas of syndemics and chronicity theories allow critical scholars to attend to the macrosocial factors contributing to the rise of noncommunicable diseases while still honoring the diversity of experiences that make individual illness experiences, and actual outcomes, unique. Such an approach not only promotes a more integrative medical anthropology, but also contributes to global health dialogues around diabetes, depression, and their overlap.
Mendenhall, Emily, and Lesley Jo Weaver. 2014. “Reorienting Women’s Health in Low- and Middle-Income Countries: The case of depression and type 2 diabetes.” Global Health Action 7: 22803 (5 pages).
Women’s health in low- and middle-income countries (LMICs) has historically focused on sexual and reproductive health. However, understanding how women acquire, experience, and treat non-reproductive health conditions, such as non-communicable diseases, has become a fundamental public health concern. Special attention to the social determinants of LMIC women’s health can provide socially and culturally relevant knowledge for implementation of policies and programs for women increasingly confronting these ‘New Challenge Diseases’. This article uses the example of depression and Type 2 diabetes comorbidity to illustrate how attending to the social determinants of mental and physical health beyond the reproductive years contributes to a more holistic agenda for women’s health. For instance, we must address the plurality of experiences that shape women’s health from social determinants of depression, such as gendered subjugation within the home and public sphere, to the structural determinants of obesity and diabetes, such as poor access to healthy foods and health care. Attending to the complexities of health and social well-being beyond the reproductive years helps the women’s global health agenda capture the full spectrum of health concerns, particularly the chronic and non-communicable conditions that emerge as life expectancy increases.
Seligman, Rebecca, Emily Mendenhall, Maria Valvidonos, Alicia Fernandez, Elizabeth A. Jacobs. 2014. “Self-care and subjectivity among Mexican diabetes patients in the United States.”Medical Anthropology Quarterly, 29(1): 61-79.
Type 2 diabetes is considered a public health crisis, particularly among people of Mexican descent in the United States. Clinical approaches to diabetes management increasingly emphasize self‐care, which places responsibility for illness on individuals and mandates self‐regulation. Using narrative and free‐list data from a two‐phase study of low‐income first‐ and second‐generation Mexican immigrants living with diabetes, we present evidence that self‐care among our participants involves emotion regulation as well as maintenance of and care for family. These findings suggest, in turn, that the ideology of selfhood on which these practices are based does not correspond with the ideology of selfhood cultivated in the U.S. clinical sphere. Divergence between these ideologies may lead to self‐conflict for patients and the experience of moral blame. We argue that our participants use their explanations of diabetes causality and control as a form of self‐making, which both resists such blame and asserts an alternative form of selfhood that may align more closely with the values held by our Mexican‐American participants.
Mendenhall, Emily, Shane A. Norris, Rahul Shidhaye, Dorairaj Prabhakaran. 2014. “Depression and Type 2 Diabetes in Low and Middle Income Countries: A Systematic Review.” Diabetes Research and Clinical Practice 103: 276–285.
Eighty percent of people with type 2 diabetes reside in low- and middle-income countries (LMICs). Yet much of the research around depression among people with diabetes has been conducted in high-income countries (HICs). In this systematic review we searched Ovid Medline, PubMed, and PsychINFO for studies that assessed depression among people with type 2 diabetes in LMICs. Our focus on quantitative studies provided a prevalence of comorbid depression among those with diabetes. We reviewed 48 studies from 1,091 references. We found that this research has been conducted primarily in middle-income countries, including India (n = 8), Mexico (n = 8), Brazil (n = 5), and China (n = 5). There was variation in prevalence of comorbid depression across studies, but these differences did not reveal regional differences and seemed to result from study sample (e.g., urban vs rural and clinical vs population-based samples). Fifteen depression inventories were administered across the studies. We concluded that despite substantial diabetes burden in LMICs, few studies have reviewed comorbid depression and diabetes. Our review suggests depression among people with diabetes in LMICs may be higher than in HICs. Evidence from these 48 studies underscores the need for comprehensive mental health care that can be integrated into diabetes care within LMIC health systems.
Bearnot, Benjamin, Angela Coria, Brian S. Barnett, Eva H. Clark, Matt G. Gartland, Devan Jaganath, Emily Mendenhall, Lillian Seu, Ayaba G. Worjohoh, Catherine L. Carothers, Sten Vermund, Doug Heimburger. 2014. “Global Health Research in Narrative: A Qualitative Look at the FICRS-F Experience.” Am J Trop Med Hyg. Epub Sep 22. pii: 13-0481.
For American professional and graduate health sciences trainees, a mentored fellowship in a low- or middle-income country (LMIC) can be a transformative experience of personal growth and scientific discovery. We invited 86 American trainees in the Fogarty International Clinical Research Scholars and Fellows Program and Fulbright–Fogarty Fellowship 2011–2012 cohorts to contribute personal essays about formative experiences from their fellowships. Nine trainees contributed essays that were analyzed using an inductive approach. The most frequently addressed themes were the strong continuity of research and infrastructure at Fogarty fellowship sites, the time-limited nature of this international fellowship experience, and the ways in which this fellowship period was important for shaping future career planning. Trainees also addressed interaction with host communities vis-à-vis engagement in project implementation. These qualitative essays have contributed insights on how a 1-year mentored LMIC-based research training experience can influence professional development, complementing conventional evaluations. Full text of the essays is available at http://fogartyscholars.org/.
Ibanez-Gonzalez, Daniel, Emily Mendenhall, and Shane A. Norris. 2014. “A mixed methods exploration of patterns of healthcare utilization of urban women with non-communicable disease in South Africa.” BMC Health Services Research, 14:528.
Background Despite the growing burden of NCDs in South Africa, very little is known about how people living in urban townships manage these illnesses. In this article we expound upon the findings of a study showing that only one-third of women with an NCD participating in the Birth to Twenty (Bt20) cohort study of Soweto-Johannesburg, South Africa, had sought biomedical services in the previous six months. Methods We evaluated quantitative data from a cross sectional health access survey conducted with adult women (mean age = 44.8) and examined 25 in-depth narrative interviews with twelve women who self-reported at least one NCD from the larger study. Results The qualitative findings highlight the potential role of negative experiences of healthcare services and biomedicine in delaying the seeking of healthcare. Multivariate analysis of the quantitative findings found that the possession of medical aid (OR = 1.7, CI = 1.01-2.84) and the self-reported use of patient strategies in negotiating healthcare access (OR = 1.6, CI = 1.04-2.34) were positively associated with the utilization of healthcare services. Belief in the superior efficacy of traditional healers over doctors was associated with delay of NCD treatment (OR = 2.4, CI = 1.14-4.18). Conclusion Our data suggest that low healthcare utilization is due in part to low rates of expectation for consistent and high-quality care and potential mistrust of the medical system. We conclude that both demand-side and supply-side measures focusing on high trust management practices will prove essential in ensuring access to healthcare services.
Lara Muñoz, María del Carmen, Elizabeth A. Jacobs, Marco Antonio Escamilla, and Emily Mendenhall. 2014. “Do women with diabetes experience depression equally in urban centers in Mexico and the United States? A comparative study.” Revista Panamericana de Salud Pública/Pan American Journal of Public Health, 36(4):225-231.
OBJECTIVE: To compare the prevalence and patterns of depressive symptoms among women with type 2 diabetes in Puebla, Mexico, and Chicago, United States. METHODS: Two cross-sectional studies were conducted independently, in Puebla (September 2010-March 2011) and in Chicago (January-July 2010). Depression symptomatology was evaluated in a random sample of 241 women self-reporting type 2 diabetes in Puebla and a convenience sample of 121 women of Mexican descent seeking care for type 2 diabetes in Chicago. Depressive symptomatology was measured by the Center for Epidemiologic Studies Depression Scale administered in either English or Spanish. Women were similarly socioeconomically disadvantaged with low education levels in both locations. RESULTS: The Chicago sample of women reported higher levels of depression than the Puebla sample (38% versus 17%, P < 0.0001). Among those with comorbid depression and diabetes in both sites, minimal variations in symptoms were observed. Depressive symptoms, specifically the subjective element (feeling sad) and symptoms associated with diabetes (fatigue and sleep problems) were heightened in both groups. More frequent reporting of “feeling fearful” was statistically significant in Puebla. CONCLUSIONS: Despite a higher prevalence of depression among Mexican immigrant women with diabetes in the United States compared to Mexico, there was little variation in their depressive symptoms, regardless of residence. However, women in Mexico did report a higher incidence of fear. Screening for depression in patients with diabetes should take into account symptoms of fatigue and sleep and the bi-directional relationship of depression and diabetes.
Mendenhall, Emily, Linda Richter, Alan Stein, Shane Norris. 2013. “Psychological and Physical Co-Morbidity among Urban South African Women.” PLOS One 8(10): e78803.
Objectives There is substantial evidence for the links between poverty and both physical and mental health; but limited research on the relationship of physical and mental health problems exists in low- and middle-income countries. The objective of this paper is to evaluate the prevalence and co-morbidity of psychological distress among women with common physical diseases in a socio-economically disadvantaged urban area of South Africa. Methods Women enrolled in the Birth to twenty (Bt20) cohort study were evaluated for this paper. Bt20 was founded in 1990 and has followed more than 3,000 children and their caregivers since birth; this study evaluates the health of the caregivers (average age 44) of these children. Psychological distress was evaluated by administering the General Health Questionnaire (GHQ-28) and we evaluated the presence of physical disease by self-report. Results Forty percent of the sample presented with psychological distress using the GHQ scoring method. More than half of the women who reported a history of a physical disease, including diabetes, heart attack, asthma, arthritis, osteoporosis, epilepsy, and tuberculosis, reported psychological disorder. Presence of one physical disease was not associated with increased rates of psychological distress. However, women who reported two diseases had increased rates of psychological symptoms, and this upward trend continued with each additional physical disease reported (measured to five). Conclusions These data indicate high prevalence rates of co-morbid psychological distress among women with physical disease. This argues for the need of greater mental health support for women living with physical diseases.
Shidhaye, Rahul, Emily Mendenhall, Kathakie Sumathipala, Athula Sumathipala, Vikram Patel 2013. “Association of Somatoform Disorders with Anxiety and Depression in Women in Low- and Middle-Income Countries: A Systematic Review.” International Review of Psychiatry 25(1): 65–76.
Background Across cultures, women are more likely than men to report somatoform disorders (SD), depression and anxiety. The aim of this article is to describe the co-morbidity of SD with depression/anxiety and to investigate the possible mechanisms of this relationship in women in low and middle income countries (LMIC). Methods We reviewed two databases: Medline and PsychINFO from 1994 to 2012 for studies which assessed the association between any SD and depression/ anxiety in women from LMIC. Our focus was on community and primary health care based studies. Both quantitative and qualitative studies were included. Results 21 studies covering eight LMICs were included in our analysis. Our findings suggest a strong association between SD and depression/anxiety (with odds ratios ranging from 2.5-3.5), though we also observed that the majority of women with SD did not have depression/anxiety. The likely mechanisms for this association are multidimensional, and may include shared etiologies, that both conditions are in fact variants of the same primary mental disorder, and that one disorder is a risk factor for the other. Anthropological research offers a number of frameworks through which we can view these mechanisms. Conclusion The current evidence indicates that service providers at the primary care level should be sensitized to consider SD in women as variants of CMD and address both groups of disorders concurrently. Further research should explicitly seek to unpack the mechanisms of the relationship between SD and CMD.
Mendenhall, Emily, Roopa Shivashankar, Nikhil Tandon, Mohammad K. Ali, K. M. Venkat Narayan, Dorairaj Prabhakaran. 2012. “Stress and Diabetes in Socioeconomic Context: A Qualitative Study of Urban Indians.” Social Science and Medicine 75: 2522-2529.
Type 2 diabetes has escalated in urban India in the past two decades. Historically a disease of the affluent, recent epidemiological evidence indicates rising diabetes incidence and prevalence in urban India’s middle class and working poor. Although there is substantial qualitative data about people with diabetes from high-income countries, scant resources provide insight into diabetes experiences among those in India, and lower-income groups specifically. In this article, we use individual-level analysis of illness narratives to understand how people experience and understand diabetes across income groups in Delhi, India. We conducted in-depth qualitative interviews and administered the Hopkins Symptoms Check-List (HSCL-25) to evaluate depression among 59 people with diabetes in northeast Delhi between December 2011 and February 2012. We analyzed their responses to: 1) what caused your diabetes?; 2) what do you find most stressful in your daily life?; and 3) where do you seek diabetes care? We found few people held diabetes beliefs that were congruent with socio-spiritual or biomedical explanatory models, and higher income participants commonly cited “tension” as a contributor to diabetes. Stress associated with children’s futures, financial security, and family dynamics were most commonly reported, but how these subjective stresses were realized in people’s lives varied across income groups. Depression was most common among the poorest income group (55%) but was also reported among middle- (38%) and high-income (29%) participants. One-quarter of respondents reported diabetes distress, but only those from the low-income community reported co-occurring depression and these respondents often revealed poor access to diabetes care. These data suggest that lower-income populations not only have higher rates of depression but also may be more likely to delay health care and therefore develop diabetes complications. This research has many implications for public health care in India as diabetes prevalence shifts to affect lower income groups who concurrently experience higher rates of depression and poorer access to medical care.
Mendenhall, Emily, Gitanjali Narayanan and Dorairaj Prabhakaran. 2012. “Depression and Diabetes in India: Perspectives and Recommendations.” Diabetic Medicine 29(9):e308-11.
As diabetes prevalence shifts from affluent to lower‐income groups in India, focus on depression in diabetes will become essential. This paper describes four perspectives through which depression and diabetes should be understood in the Indian context. We consider (1) how rapid socio‐economic and demographic changes contribute to increased co‐occurring diabetes and depression; (2) how social, cultural and economic factors in the Indian context contribute to depression and therefore play an important role in diabetes care; (3) biological and behavioural pathways between depression and diabetes; and (4) the role of health systems in depression, diabetes and their overlap. We conclude with recommendations for future research and policy on this topic in India.
Mendenhall, Emily, Alicia Fernandez, Nancy Adler, and Elizabeth A. Jacobs. 2012. “Susto, Coraje, and Abuse: Depression and Beliefs about Diabetes.” Culture, Medicine and Psychiatry 36(3): 480-492.
Mexican immigrants in the US often incorporate folk beliefs into diabetes etiologies but little is known about the relationship between such beliefs and depression. This study examines the relationship of diabetes beliefs and depression among 404 first- and second-generation Mexican immigrants seeking diabetes care in safety-net clinics in Chicago and San Francisco. We used multivariate linear regression to compare the association of depression with beliefs that susto (fright), coraje (anger), and/or interpersonal abuse cause diabetes, adjusting for gender, age, income, education, diabetes duration, co-morbidities, language preference, and acculturation. We incorporated the belief that abuse causes diabetes based on previous ethnographic research. Individuals reporting belief that abuse contributes to diabetes were significantly more likely to report symptoms of depression before (β = 1.37; p < 0.05) and after adjustment (β = 2.03; p < 0.001). Believing that susto and/or coraje cause diabetes was not significantly associated with depression before or after adjustment. The significant association between depression and belief that abuse contributes to diabetes onset suggests that belief in a specific form of social distress may be more closely associated with depression among people with diabetes than a folk belief such as susto or coraje.
Mendenhall, Emily, and Elizabeth A. Jacobs. 2012. “Interpersonal Abuse and Depression among Mexican Immigrant Women with Type 2 Diabetes.” Culture, Medicine and Psychiatry 36(1): 136-153.
Evidence for a bi-directional relationship of depression and type 2 diabetes suggests that social distress plays a role in depression among people with diabetes. In this study, we examine the relationship between subjective distress and depression in 121 first- and second-generation Mexican immigrant women seeking diabetes care at a safety-net hospital in Chicago. We used a mixed-methods approach including narrative interview, survey, and finger-stick blood HbA1c data. Using grounded theory analysis, we identified seven life stressors from narrative interviews: interpersonal abuse, stress related to health, family, neighborhood violence, immigration status, and work, and feeling socially detached. Women reported unusually high rates of interpersonal abuse (65%) and disaggregated physical abuse (54%) and sexual abuse (23%). We evaluated depression using CES-D cut-off points of 16 and 24 and assessed rates to be 49 and 34%, respectively. We found that interpersonal abuse was a significant predictor of depression (CESD ≥ 24) in bivariate (OR 3.97; 95% CI 1.58–10.0) and multivariate (OR 5.51; 95% CI 1.85, 16.4) logistic regression analyses. These findings suggest that interpersonal abuse functions as an important contributor to depression among low-income Mexican immigrant women and should be recognized and addressed in diabetes care.
Lynch, Elizabeth, Alicia Fernandez, Nicole Lighthouse, Emily Mendenhall, and Elizabeth Jacobs. 2012. “Concepts of diabetes self-management in Mexican American and African American low-income patients with diabetes.” Health Education Research 27(5): 814-24.
The goal of the study was to explore low-income minority patients’ concepts of diabetes self-management and assess the extent to which patient beliefs correspond to evidence-based recommendations. African American and Mexican American patients with type 2 diabetes were recruited from safety net clinics that serve the uninsured and under-insured in Chicago and San Francisco to participate in focus group discussions. Grounded theory was used to identify themes related to diabetes self-management. Strategies participants mentioned for diabetes self-care were medication use, diet, weight loss and exercise. Eating more fruit and vegetables and consuming smaller portions were the most commonly mentioned dietary behaviors to control diabetes. African Americans expressed skepticism about taking medications. Mexican Americans discussed barriers to acquiring medications and use of herbal remedies. Mexican Americans frequently mentioned intentional exercise of long duration as a management strategy, whereas African Americans more frequently described exercise as regular activities of daily living. Blood glucose self-monitoring and reducing risks of diabetes complications were rarely mentioned as diabetes self-management behaviors. African American and Mexican American patients have different concepts of diabetes self-management, especially with regard to medication use and physical activity. Consideration of these differences may facilitate design of effective self-management interventions for these high-risk populations.
Mendenhall, Emily, Rebecca Seligman, Alicia Fernandez, Elizabeth A. Jacobs. 2010. “Speaking through diabetes: Rethinking the significance of lay discourses on diabetes.” Medical Anthropology Quarterly 24(2): 220-239.
The disproportionate prevalence of Type II diabetes mellitus among the poor suggests that, in addition to lifestyle factors, social suffering may be embodied in diabetes. In this article, we examine the role of social distress in narratives collected from 26 Mexican Americans seeking diabetes care at a public hospital in Chicago. By linking social suffering with diabetes causality, we argue that our participants use diabetes much like an “idiom of distress,” leveraging somatic symptoms to disclose psychological distress. We argue that diabetes figures both as an expression and a product of social suffering in these narratives. We propose that increasingly prevalent chronic diseases, like diabetes, which are closely associated with social disparities in health, may function as idioms for psychological and social suffering. Such findings inform the anthropological literature and emerging clinical and scientific discourse about the roles of stress and psychological distress in diabetes experiences among underserved groups.
Wagner, Julie, Chandra Osborn, Emily Mendenhall, Lisa Budris, Sophia Belay, Howard Tennen. 2011. “Beliefs about Racism and Health among African American Women with Diabetes: A Qualitative Study.” Journal of the National Medical Association, 103(3): 224–232.
Exposure to racism has been linked to poor health outcomes. Little is known about the impact of racism on diabetes outcomes. This study explored African American women’s beliefs about how racism interacts with their diabetes self-management and control. Four focus groups were conducted with a convenience sample of 28 adult African American women with type 2 diabetes who were recruited from a larger quantitative study on racism and diabetes. The focus group discussions were transcribed verbatim and analyzed by the authors. Women reported that exposure to racism was a common phenomenon, and their beliefs did in fact link racism to poor health. Specifically, women reported that exposure to racism caused physiological arousal including cardiovascular and metabolic perturbations. There was consensus that physiological arousal was generally detrimental to health. Women also described limited, and in some cases maladaptive, strategies to cope with racist events, including eating unhealthy food choices and portions. There was consensus that the subjective nature of perceiving racism and accompanying social prohibitions often made it impossible to address racism directly. Many women described anger in such situations and the tendency to internalize anger and other negative emotions, only to find that the negative emotions would be reactivated repeatedly with exposure to novel racial stressors, even long after the original racist event remitted. African American women in this study believed that racism affects their diabetes self-management and control. Health beliefs can exert powerful effects on health behaviors and may provide an opportunity for health promotion interventions in diabetes.
Jacobs, Elizabeth A., Emily Mendenhall, Ann S. McAlearney, Italia Rolle, Eric Whitaker, Richard Warnecke, Carol E. Ferrans. 2011. “An exploratory study of how trust in health care institutions varies across African American, Hispanic and white populations.” Communication and Medicine, 8(1):89-98.
BACKGROUND: Minority and non-minority patients in the United States have different levels of trust in health care; however, few studies have examined how determinants of trust and distrust in health care vary across diverse groups. OBJECTIVE: To explore how trust in health care institutions varies across diverse populations. METHODS: We conducted 17 focus groups with 117 participants in Chicago: 9 with African American, 5 with Hispanic, and 3 with white participants. Discussions were audiotaped, transcribed verbatim and coded using grounded theory analysis to identify dominant themes. RESULTS: We found a core set of factors that contribute to trust and distrust across racial/ethnic groups. In addition, there were unique factors that contributed to distrust among African Americans and Hispanics. Both of these groups discussed expectations of discrimination in the health care setting and African Americans discussed expectations of being experimented on as determinants of distrust. Based on these findings, we developed a hypothetical model of how different factors influence trust and distrust in health care across these different racial/ethnic groups. CONCLUSIONS:
Contributors to trust and distrust in health care institutions are not always uniform across racial/ethnic groups. These differences should be addressed in future research and efforts to enhance trust in health care institutions.
Mendenhall, Emily, L Muzizi, Rob Stephenson, Elwyn Chomba, Allen Haworth, Susan Allen. 2007. “Property Grabbing and Will Writing in Lusaka, Zambia: An Examination of Wills of HIV Infected Cohabiting Couples.” AIDS Care 19(3): 369-74.
High rates of HIV and poverty place women in a precarious economic situation in Lusaka, Zambia. Mortality from HIV infection is high, leaving many households single headed and creating almost a half a million orphans. One of the most prevalent forms of gender violence that creates poverty in women is when the male’s family claims the property of the deceased from the widow and the children. The Zambia-Emory HIV Research Project collected 184 wills from individuals in monogamous unions where one or both of the individuals were HIV-positive. Despite the fact that many wills specifically stated that their extended family was not allowed to tamper with their possessions in the event of death, property grabbing proved to be a prevalent and difficult issue in Lusaka. In order to improve the lives of widowed women in Lusaka, the government and other civic and non-governmental organisations must inform women of their rights to own and protect their land and other assets in the event of their husbands’ death, an issue of increasing importance in the area of HIV/AIDS.
Stephenson, Rob, Emily Mendenhall, L Muzizi, Bellington Vwalika, Elwyn Chomba, Yusuf Ahmed, L Clark, D Roth, J Telfair, A Haworth, Susan Allen. 2008. “The Influence of Motivational Messages on Future Planning Behaviors Among HIV Concordant Positive and Discordant Couples in Lusaka, Zambia.” AIDS Care 20(2): 150-160.
In Zambia the HIV/AIDS epidemic has resulted in many single female-headed households. Strong patriarchal laws and customs prevent widows and children from maintaining economic assets. This study examines the impact of a video-based motivational intervention promoting future planning in 1,504 HIV-infected couples in Lusaka, Zambia. Following a group video session, couples randomized to the motivational arm could choose to write a will, identify a guardian for their children and make financial plans. Desirable behaviours modelled in the motivational video were measured at quarterly intervals for a year and compared in intervention and control arms. Demographic measures including age, income and educational status were not associated with planning behaviours. Participation in the intervention was associated with will writing (23% versus 5%) and naming a guardian (32% versus 17%) but not with other planning behaviours. The study demonstrates the ability of motivational messages integrated into HIV VCT to encourage future planning behaviour and points to the need to expand existing HIV and VCT services to meet other non-health needs of those living with HIV.
Book Chapters in Edited Volumes
Mendenhall, Emily. 2016.“Syndemic Suffering: Rethinking Distress and Diabetes among Mexican Immigrant Women.” In Understanding and Applying Medical Anthropology. Eds, Peter. J. Brown and Svea Closser. Routledge.
Kohrt, Brandon, and Emily Mendenhall. 2015. “Introduction: Anthropological Perspectives in Global Mental Health.” In Global Mental Health: Anthropological Perspectives, Routledge
Kohrt, Brandon, Emily Mendenhall, and Peter J. Brown. 2015. “Historical Background: Medical Anthropology and Global Mental Health.” In Global Mental Health: Anthropological Perspectives. Routledge
Mendenhall, Emily, and Brandon Kohrt. 2015.“Anthropological Methods in Global Mental Health Research.” In Global Mental Health: Anthropological Perspectives, Routledge.
Mendenhall, Emily. 2015. “The “Cost” of Health Care: Poverty, Depression, and Diabetes among Mexican Immigrants in the United States.” In Global Mental Health: Anthropological Perspectives, Routledge.
Kohrt, Brandon, Emily Mendenhall, and Peter J. Brown. 2015. “Conclusion: A Roadmap for Anthropology and Global Mental Health.” In Global Mental Health: Anthropological Perspectives, Routledge.
Mendenhall, Emily, and Peter J. Brown. 2016. “Global Health Education: When (and How) Global Health Issues Should Be Introduced to Youth.” Somatosphere, published online September 2.
Mendenhall, Emily. 2015. “Views on Bioculturalism.” Invited essay for series edited by Jeffrey Snodgrass for Somatosphere, published online August 10.
Mendenhall, Emily. 2015. “Creating Methods that Speak Across Disciplines in Medical Anthropology.” Invited Essay for Somatosphere, published online June 19.