Peaks and Valleys of Building Community Rapport: Lessons Learned Through an Investigation of Adolescent Sexual Health

On my graduate school journey in medical anthropology at the University of Alabama, I became curious about HIV risk while conducting fieldwork in Mobile, Alabama. There, I worked on my thesis on intergenerational body image beliefs of working class African American mothers and daughters. Mothers in my study revealed that they could tell someone had HIV by looking at them. These insights solidified my interests in determining what African American adolescent girls in Alabama knew about HIV and how social ecological factors influence both knowledge and sexual health behaviors. Alabama is an abstinence only sex education state (Minimum Contents to be Included in Sex Education Program or Curriculum, Alabama State Code Section 16-40A-2). Sexual health education is focused on abstinence until marriage, and prevention of sexually transmitted infections, including HIV/AIDS, and teen pregnancy.

The Youth Risk Behavior Surveillance reports that while risky sexual activity is decreasing among adolescents, condom use among African American high school teens during last sexual intercourse declined from 70 percent in 1999 to 65 percent in 2011. Alabama is ranked lowest in rates of condom use among high school students (Eaton et al. 2012). African Americans represent 26 percent of the state’s population, but 64 percent of reported HIV infections are from this group. Adolescents in Alabama aged 13-24 comprise 5 percent of existing HIV infections, and 32 percent of new cases reported in 2014 (Alabama Department of Public Health, 2015).

When I embarked on my journey toward this project, I was driven by anthropological theory as a way to address a public health concern. Although I did not consider a strengths-based approach to lead my inquiry regarding sexual health, I understood and respected the importance of addressing community needs as a participant observer and researcher. I recognize that dismissing assets used to address sexual health concerns is problematic. However, given the taboo nature of what I wanted to explore, I believe acknowledging these assets pose additional challenges and would not have changed the peaks and valleys experienced in my community engagement and research. Following is a brief, partial list of lessons learned through my experiences working with an anonymous African American community in Alabama. It is my hope that the suggestions put forth will prove valuable to those committed to community engagement and scholarship.

  1. Find community members supportive about what you want to learn.

Two years prior to beginning my research, I met with many community members. Among them was a school board member who worked for many years as a nurse. She developed and implemented a health initiative program where I happened to volunteer one summer prior to meeting her. Because of this established rapport through familiarity of her program, she provided me with beneficial information about health issues, community life and how to effectively engage with other members. She recommended members and organizations, as she ended many of our conversations saying, “Tell them I sent you.” This type of advocacy was essential to discovering where my skills could be used in the community while simultaneously researching sexual health issues among teen girls.

  1. Understand that what scholars, governmental institutions, and non-profit organizations view as important, community members may not judge similarly.

When establishing rapport in the early stages of my research, a professor suggested I meet a pastor amenable to research. This pastor was extremely welcoming, although, early on in our conversation, he stated that his church members do not really talk about HIV or believe it is a major problem in the community. In addition, I attended a high school parent meeting provided by a local health organization discussing sexual health and sexually transmitted infections. Notably, only two school administrators and myself attended this meeting, even though parents were given advanced notice of the seminar.

I discovered early on that difficulty in trying to research a stigmatizing topic is the strong desire for community members to separate themselves from the issue through attempting to achieve mainstream social norms, values, and conduct. This also creates difficulty in using a strengths-based approach, since assets may not be used for the purpose of addressing a proscribed issue that community members approach in denial.

  1. Find a place where you fit in and build community relationships.

After explaining my project to numerous community members, I had a difficult time having people take me seriously, return my calls, or acknowledge me in public. Initially, I spoke with middle class community members to gain entrée into the community, establish where I could assist with community needs, and determine the best way to learn what young teenage girls knew about HIV risk. For example, I approached another pastor who was willing to assist, but was ultimately too busy to accommodate me in his church. This early acceptance and eventual rejection happened frequently. While this pastor was too occupied to assist me, he introduced me to the director of a neighborhood center centrally located in a working class community, and this introduction proved to be extremely valuable.

The neighborhood center resulted in collaboration with the director where I fulfilled both community engagement and research roles. The center provides residents with numerous services including computer classes, GED classes, a Chess Club, and after-school and summer programs for youth. Upon my introduction to the community, the director asked if I would be interested in teaching GED. classes. I jumped at the chance to serve this community that was welcoming to my presence and could utilize my academic skills. I taught math GED classes weekly for a fall and spring semester to men and women in the community.

The women I taught were extremely helpful to my understanding of community dynamics. Understanding community interactions was useful given that I took a social ecological perspective to HIV risk in my research. Women shared that conflict centered on arguing over men who were unfaithful in not only the local community where the center was centrally located, but also in an adjacent governmental housing area. Remarkably, one of the women revealed that higher sexual risk was associated with a woman’s male partner having a concurrent relationship with someone outside of the immediate neighborhood. If their boyfriend had a sexual relationship with a woman in the governmental housing neighborhood or beyond the immediate community, it was believed that sexual health risk increased greatly because the sexual partners that their boyfriend was concurrently dating was unfamiliar. Given that the women were aware of gossip regarding illnesses that other women in the local community held, it was viewed as a higher risk situation when information about the health of potential sex partners outside of the community was not readily available, whether this information is true or not.

After spending some time in the community, I interviewed younger girls in the neighborhood who shared various characteristics and behaviors associated with HIV risk which highlighted socio-ecological factors important to this topic. High risk was associated with lack of parental investment, hanging out in the neighborhood, running away from home, and transactional sex. In contrast, low risk was associated with parental investment, staying at home, interest in academic pursuits and future goals, and involvement in church.

  1. Do not take it personally when you run into a person or people who are unsupportive. Avoid flattery and move on to someone willing to assist.

A school administrator that worked closely with the students shared some of the experiences of the girls that attended the community high school where I observed. At the outset, she was forthcoming about issues faced by female students including domestic violence, sexual abuse, teenage pregnancy and abortions. Through this first conversation, this administrator mentioned that she mentored and advised two in-school programs for girls that experienced these concerns. I looked forward to observing these programs, hoping to get a sense of how these students understood sexual health through their lived experiences. Afterwards, the administrator noted that she would have to ask permission to allow me to gain access to these programs and observe students.

After a great deal of effort to contact her in the days and weeks following our conversation, I emailed her to see if I would be more successful in contacting her in that manner. This approach worked, with a brief email returned almost immediately. Unfortunately, the administrator noted that aside from the Principal of the school, she also answered to another supervisor at the department of education. Her supervisor advised that she was not under any responsibility to assist me in understanding issues related to sexual health, and wished me the best in my endeavors.

I was not surprised by the eventual demise of our communication, although the situation was extremely discouraging. After the dust settled, I asked some colleagues in anthropology and the school board member (see lesson #1 above) for advice on the situation. My colleagues thought I should try to establish rapport with her by finding out what she liked and buying it for her. This was not bad advice from anthropologists since we are trained that participant observation “involves getting close to people and making them feel comfortable enough with your presence so that you can observe and record information about their lives. […] Only by confronting the truth about participant observation—that it involves deception and impression management—can we hope to conduct ourselves ethically in fieldwork“ (Bernard 2006:342). With this training, it makes sense that fellow anthropologists would advise me to build rapport using this method.

In contrast, when I met with the school board member over lunch one afternoon, she stated that there would always be someone who does not approve of the work being done in the community, and that people would stand in the way. She advised that I should simply go around the school administrator and find someone able to help with what I need—a suggestion that really spoke to who I am personally. I could not imagine having a disingenuous relationship with this woman who is extremely busy with her own responsibilities. Eventually, I became grateful for the little time where we sat together and she shared valuable information about the girls that she serves through her employment at the school. Fortunately, I did bypass this school administrator and found allies with amazing teachers and other administrators who supported my observation in the school.

To conclude, this journey to understand sexual health concerns and risks among African-American teenagers taught me a great deal. I learned the value of community engagement on a level of incorporating my skills to meet the needs of those who valued my presence, even though they may have thought I was strange for asking about community dynamics or why some girls were viewed as high or low risk of HIV. One of the most valuable things I learned is that if there is sincerity in your desire to assist in what the community deems important, community members will value that goodwill and add to your scholarship by revealing more about their lives than initially hoped.

Tina Thomas (PhD, University at Alabama, 2016) is a Postdoctoral Fellow in Anthropology at Juniata College. She studies the intersection of culture, social ecology, and health in the U.S.

What’s Biological about Biocultural Research? (Part 2)

We inhabit an academic universe of disciplines, sub-disciplines, and sub-sub-disciplines guarding their borders. Holism is not dead, but we struggle with what it means.

If biocultural research is to be useful, it needs to be inclusive, flexible, and not defensive. For instance, many researchers in the positivist anthropological sciences rail against or just ignore theory and practice Foucault’s biopower, the de-colonization movement, or critical medical anthropology. Yet one of the compelling features of anthropology is that every foundational assumption can and should be examined.

Biocultural research has the potential to be a transactional phenomenon without a set trajectory. By transactional I mean we converge on understanding human experience that incorporates the subjectivity and physicality of the body in the world and describes exchanges among them. Every element of human state regulation, from gene regulation through neuronal firing patterns and hormone release to complex phenotypes like a disease state or  developmental outcome, is shaped by subjective experience, meaning it is shaped by culture.

Yet research design should target specific biocultural transactions. I propose a rough taxonomy of ways biology can be incorporated into biocultural research:

1)   Biocultural by theory. Strong research programs are grounded in theory, and biocultural research must include biocultural transactions, as research by our Alabama graduates demonstrates. Tufts U medical student Catherine Buzney and I drew from life history theory, to hypothesize and interpret linkages between childhood stress and pubertal timing. In another study, I used ecocultural theory to interpret child stress response patterns and young adults’ physical activity. Mississippi State U Assistant Professor Toni Copeland examined health outcomes among poor HIV-positive women in Kenya through the lens of structural violence. Rick Brown and East Carolina U Teaching Assistant Professor Blakely Brooks built a cultural epidemiology of Type 2 diabetes and Susto, respectively. Bill Dressler, Kathy Oths, Utah State U Assistant ProfessorFrancois Dengah use cultural consonance theory to bridge cognitive culture theory and stress theory and to examine how cultural meaning shapes arterial blood pressure, depressed affect, and body mass. Within this theoretical pattern, these projects are firmly founded in some well-developed theoretical framework that demands reference to the human body and its workings.

2)   Biocultural by outcome. Theory may encourage examination of transactions between subjectivity and physicality of the body, but it’s still necessary to actually study those transactions. In our program, we emphasize testing of hypotheses concerning measurable health outcomes. These can be physiological, such as U of Florida post-doc Sarah Szurek’s findings regarding glycemic control, Bill Dressler’s work on hypertension, or work that Chris Lynn and I have done regarding immune function. The outcomes may be implicitly biological, such as Kathy Oths’ work on bone setting and Debilidad. Because this research benefits from quantification, mixed-methods approaches are essential to biocultural research. Biocultural anthropologists build those statistical models on an ethnographic foundation.

3)   Biocultural by marker. I noted previously that biomarkers are neither necessary nor sufficient to a biocultural study. They’re still pretty darn useful, though. As I use the term, a marker is distinct from an outcome in that it is not the target of inquiry but helps to describe or quantify another important but less measurable variable. Cortisol, for instance, is a marker of stress but not stress itself. C-reactive protein is a marker of inflammation. Genotypes, too, are markers of gene expression and variation in biological function. Serotonin receptor polymorphisms are markers of biological sensitivity to adversity.

Depending on study design, sometimes markers can serve as outcomes. Chronic inflammation can be a marker of pathogen exposure or an outcome of interest. Blood pressure can be a stress marker or an outcome measure of hypertension. Research can be biocultural by marker when the biomarker serves as a tool to address a question otherwise inaccessible to study.

4)   Biocultural by extension. Research can begin with a biological outcome but lead in a direction that encourages a less direct approach to biology. This is a satisfying upshot of biocultural research because it concerns the development of an entire research program rather than a single study. Current Alabama doctoral student Martina Thomas began her research by examining cultural models concerning body image among African-American adolescents and mothers in a low-income community with high obesity rates. She found that body image, rather than being strictly concerned with shape or size, was bound in a complex model involving social relationships, material possessions, with behaviors including respectfulness, drug use, and gossip. There were hints regarding perceptions of what a person with AIDS looks like from which Thomas built an entirely new study examining HIV/AIDS models and social ecologies of risk. This research is not only biocultural by outcome but also biocultural by extension. It follows a trail of evidence leading into social and behavioral research without direct measurement of biological markers or outcomes, and there is no wall preventing the researcher from following along.

5)   Biocultural by interpretation. Finally, research may be interpreted in light of human biology without measuring it. Francois Dengah and Chris Lynn did work concerning dissociative states evoked in Pentecostal rituals. They don’t measure the neurobiology of dissociation, but they know about it, interpreting their findings in light of neurobiology (and stress biology, which Lynn measured and Dengah inferred). A hallmark of neuroanthropology is the interpretation of cultural and social experiences (from cancer survivorship to drug use and sport) in terms of neurobiology.

Anthropologists have an advantage as we get outside of the lab and learn about lived experience. We examine questions that no other discipline is equipped to handle, but only if we’re prepared to transgress boundaries. Otherwise, we may as well let the physiologists do it. After all, they have more money and fancier toys.

This post was previously published in Anthropology News’ June 2015 “Knowledge Exchange.”