Partnerships for Global Health: Putting theory into practice

For our latest DEPTH blog we asked LSHTM researcher Kimberley Popple to share her thoughts on NGO-academic collaborations as someone who has recently moved from the former to the latter. Thank you for your insights Kimberley – lots of food for thought!

Image: Dan Dimmock for Unsplash

Evaluation, Evaluation, Evaluation

Back in January this year I made the move from practitioner in the NGO world to becoming a researcher in the academic sector. I wanted to combine the skills I had developed in Public Health research with my knowledge and experience of programme implementation in the field.  It seemed to me that there were obvious synergies and opportunities for practitioners and academics to work together to improve global health. Certainly, from my own experience, the projects that I worked on could have benefited from drawing on people with specialist skillsets in data collection and analysis and with the time to conduct literature reviews, produce evidence maps, and test the change pathways that many of the programmes were built upon.

Before moving into academia, I worked on a large portfolio of grants in Sierra Leone as part of the Ebola response.  Most of the data we collected was used solely for routine monitoring and evaluation of interventions at the project-level. Its purpose was to track progress against set indicators and to report on spending to funders. As a result, collecting data that could be easily quantified was prioritised, and quantitative data was assumed by funders to show a greater impact than qualitative data. Further, qualitative data tends to fall within the remit of the accountability teams – it is used and relied upon but not as an indicator of impact. In the Sierra Leone scenario, success of an intervention was often measured by a high number of medical consultations or a large number of attendees at a meeting, rather than focusing on data related to quality of services or patient satisfaction. I remember one example of a gender-based violence (GBV) project in Freetown which was categorised by the funder as “underperforming” as the target number of survivors had not been reached. The fact that that the women who had been reached had received high quality support across the GBV spectrum of services was seemingly less valued. 

In Uganda, I worked on a maternal health project which introduced a client-exit survey for women to participate in at the hospital after receiving maternity care. However, the survey was administered by NGO staff who were working with the marginalised populations, and in close proximity to the medical staff who had provided their care. There was little recognition of the power imbalance between interviewer and interviewee or the desirability bias that might be present as a result of the women’s fear of negative repercussions from medical staff.

Evaluations were often seen as a tick-box exercise for donors and their design was fairly rudimentary. By the time the evaluation report was written, the programme had already moved onto the next phase to align with strict funding cycles. This left little room to reflect on lessons learned and engage in a process of iterative programme design. A recent systematic review has highlighted the lack of evaluations conducted on epidemic responses in humanitarian and low-income settings, with only one tenth of responses evaluated and with large gaps in quality, content and coverage of evaluations, limiting the ability to improve future responses.

Image: Dan Dimmock for Unsplash

Is the landscape changing?

Over recent years, the international development sector has intensified its focus on evidence-based programming and evaluation.  Many NGOs have increased their research capacity with dedicated departments and research staff (for example Airbel Impact Lab at International Rescue Committee, and the Response Innovation Lab at Save the Children), giving them the expertise and space to test out new formats for implementation, and to ensure programming is based on the latest evidence of what works.

New funding streams have emerged for research in the humanitarian field, such as Elrha’s R2HC programme, and there is donor pressure to evidence learning and use data for decision-making. Donors like the UK government’s Foreign, Commonwealth & Development Office (FCDO, formerly DFID) have developed more in-depth guidance on how to develop and use evaluation frameworks to measure impact and ensure accountability, with requests to include qualitative indicators in logframes.

What can academia bring to the table?

So, is there still a role for academics to play in supporting the work of NGOs? I believe there can be, particularly in the evaluation of complex interventions. Universities train public health professionals who often go on to work in the NGO sector. Expert knowledge of process and outcome evaluations can be drawn upon to test change pathways in Theories of Change. Systematic reviews can be performed by academics with fewer time and funding constraints, reducing the need to reinvent the wheel every time to search for the latest evidence. As academics, we can add our voice to campaigns as advocates of change. And the humanitarian health sector can harness specific skill sets in conducting clinical trials and in disease modelling. My sense is that as both sectors continue to develop and evolve, it will be important to continue to reflect on the value of academic-NGO partnerships for global health.

Image: you-x-ventures for Unsplash

Ethical research in lockdown: Options for obtaining informed consent

Self-testing swab. Photo credit: Anne Koerber, LSHTM.

The COVID-19 pandemic is requiring home-testing in large numbers, and this process raises questions about the ethics of informed consent. In our latest blog, DEPTH member Dr Catherine McGowan reflects on a route to informed consent and suggests how governments, healthcare groups and institutions can maintain informed consent in a time of crisis.

A key step in any research project involving human participants is gaining informed consent. COVID-19 has disrupted research work around the world, and it will continue to do so for many more months. In this ever-changing pandemic environment, important research must continue. However, this work still requires researchers to think carefully about how best to obtain consent remotely.

Photo credit: IEEE Spectrum

Researchers carrying out various population surveys are sending COVID-19 tests by post and encouraging people to self-test. Self-testing kits are a good example of a process that reminds us of the need to think about consent. Research participants must provide informed consent to participate in research, particularly when it comes to population surveys involving biological sample collection. Information governance in the European Union and the UK has changed considerably with the implementation of the General Data Protection Regulation (GDPR), which does not allow for presumed consent in most cases – so when it comes to a process like home testing, for example, the data gathered cannot legally be collected or processed without gaining explicit consent from research participants.

In 2017 we carried out antibody testing amongst non-Ebola infected healthcare workers (HCWs) who had returned from West Africa following the 2014/16 Ebola outbreak. We posted test kits to HCWs throughout the UK and the Republic of Ireland, with samples returned via post. When it came to getting informed consent, face to face consent was not feasible, we could not waive consent and nor did we feel comfortable presuming consent. In the interests of best practice we also wanted to make sure that participants had all of the information they needed in order to consent fully – and be able to reach us, the project PIs, with any questions they might have.  Ultimately, we decided to recruit participants via email but first they were asked to work their way through the consent materials electronically, and to explicitly indicate their consent. Once participants had consented they were asked to complete a short questionnaire and to provide their postal address so that we could send out the test kits. At the conclusion of the study we emailed participants to let them know the results of their antibody test and included a link to a survey asking about their experience of consent. Our findings, as well as a description of the design of the consent process is described in our paper which you can read for free in Journal of Public Ethics. We asked participants how much of the consent material they read, how informed they felt and if they preferred online to traditional face-to-face consent.

The results were very interesting: Participants indicated a high level of engagement with the consent materials, with 67% reporting having read all and a further 20% having read ‘most’ of the materials. All participants indicated feeling completely (78%) or mostly (22%) informed about the purpose, methods and intended uses of the research, as well as what participation was required and what risks were involved. Overall, participants reported an overwhelming preference for online consent. Their longer free-text responses suggested that they were predominantly attracted to the convenience of online consent, including the leisure to read the consent materials several times, and the ability to engage in the consent process at a convenient time/place. Free text responses also supported online consent for our survey, but participants indicated that were the study more complex or were it a clinical trial they would prefer to have a face-to-face element.

Self-testing kit. Photo: Anne Koerber, LSHTM.

Obtaining consent in lockdown

What can this study tell us about the research based on COVID-19 home-testing that is happening now? Well, it is our hope that as researchers aim to continue their work online, they give careful thought to what informed consent is in the current circumstances. Our paper describes how to obtain informed consent electronically and in a way that we have found to be acceptable amongst our research participants, but this might not be appropriate in all cases.

We also hope that Public Health England puts in place a robust framework for the pandemic to ensure adequate consent is still sought and obtained for any research. It is in times of crisis that abuses may be allowed to happen. Even with the best intentions, researchers may act expediently and may overlook best practice in their hurry to conduct the research and obtain results. In disaster settings, corner-cutting in ethical research practices are more likely, but this is also when participants are most vulnerable and may feel less able to challenge research practices that feel inappropriate. Our own study has shown that there are easy and acceptable solutions for obtaining informed consent. We hope that researchers currently developing population surveys using self-testing methods will give some thought to developing acceptable solutions to obtaining informed consent. We must continue research activities without forgetting our professional, ethical, and legal obligations to those who make our work possible.

Photo copyright: Catherine R. McGowan. Photo consent from healthcare worker.

This Sickle Cell Life, co-production & academic research

Recruitment information for This Sickle Cell Life participants (Photo: Anne Koerber)

Our latest blog by DEPTH researcher Dr Sam Miles takes a break from coronavirus research to explore the themes of co-production and collaboration in our recently completed project This Sickle Cell Life. Read on to find out more…

Regular readers of this blog will know that our work in DEPTH (Dialogue, Evidence, Participation & Translation for Health) includes thinking about how we involve different communities in health research. Today I’m writing about This Sickle Cell Life, a recently completed qualitative research project that talks to young people about their lives and experiences of having sickle cell disease. I should add that some of what I’m writing about is based on team discussions and reflections. We’re writing this up in more detail with our co-authors and I’ll keep you posted on how it progresses.

I got involved in This Sickle Cell Life with Professor Cicely Marston and Dr Alicia Renedo when I started here at LSHTM in 2017. Funded by the National Institute for Health Research (NIHR), the project explores how young people experience transitions in moving from paediatric to adult healthcare services. This includes for example how our participants experience GP surgeries, scheduled hospital visits or unscheduled (i.e. emergency) trips to A&E. We also explored the personal and day-to-day experiences of young people living with sickle cell disease. We were aiming to answer questions including: What is the relationship between a young person with sickle cell and their doctor, and how does this change if you move away from home for college, university or work? And why do young people with sickle cell sometimes delay going to the emergency department when they have a sickle cell pain crisis? (Read this excellent overview by Sickle Cell Society for more on pain). We then cast the net wider to think about family, school, sex and relationships.

Our aim was to offer a much-needed sociological picture of how a young person with sickle cell navigates their life and their future, to mirror the more extensive clinical and quantitative research that has been published about the condition. That’s not to say that sickle cell research is exactly a crowded market – Professor Simon Dyson, who has made brilliant sociological contributions over many years, has rightly noted the lack of sickle cell research compared to other chronic health conditions, and how social, economic and ethnic determinants play into this marginalisation:

‘…impairment is primarily socially created by environmental factors, consumption patterns and accidents and not by genetic disorders.’ (Dyson 1998: p.123).

sicklecells - Wikipedia commons

Sickled cells (Photo: Wikipedia Commons)

Co-production

Fieldwork was already expertly wrapped up by Alicia when I joined the project, but I got to be part of the really interesting results analysis, discussion and dissemination work, including an engagement event with the public which in turn led to some fantastic community projects of its own. You can read more about the work here, but what I’m going to focus on in this blog was the role of ‘co-production’ in the project: put simply, that means working with different ‘kinds’ of people to produce research that is a collaborative effort. Co-produced research recognises that expertise is held by a range of people rather than only the ‘usual suspects’ (in this scenario, academics or clinicians). Advocates of co-production hope that the research findings developed are more rounded-out and take into account the ‘embodied’ knowledge of people who are living the journey themselves (see Renedo et al., 2018 for more).

One of the distinctive features of This Sickle Cell Life was that it was co-produced with two young sickle cell patient experts and a sickle cell parent/carer expert from the outset. All three have extensive knowledge of sickle cell and life with sickle cell, and already advocate for healthcare improvement in their own lives. They were involved long before I was – right from the project planning and application stage before funding was granted, in fact. They were also paid for their time. Partnering with these three experts added a very important facet to the research we conducted. There is a lot of talk in public health research about ‘PPI’, or patient & public involvement with healthcare. In the NHS, the motto ‘nothing about me, without me’ represents one way in which patient involvement is rationalised. Funders and grant-giving bodies are (rightly) keen to see meaningful involvement with the communities (sometimes also called beneficiaries) who are most relevant to the research being done. Co-production can also shine a light on the power imbalances that often happen in a traditional researcher-participant relationship in social sciences research which can reinforce all sorts of unhelpful hierarchies and prejudices.

SickleCell-futures- emergency dept
Documenting the participatory dissemination event for This Sickle Cell Life (Photo: Anne Koerber)

In our project, we agreed with our patient experts that it was particularly important that their voices were heard, because they contributed expert knowledge of their bodies and their own health conditions, as well as helping us at the findings stage of the research, highlighting themes that were most pertinent to improving healthcare environments for people with sickle cell. We further argued at every stage (to colleagues, institutions, sceptics – anyone who would listen basically) that our involvement processes needed to be considered, balanced, and properly thought-through – lip-service involvement doesn’t help any party and it is not in the spirit of meaningful participation. We wanted to amplify less-heard voices and hear stories from our patient experts and carer experts because their analysis of their own, and others’, experiences of sickle were invaluable. Our collaborators’ input contributed a different side to more traditional qualitative research; as a team, we worked to interpret the data and draw out the implications for practice.

The highlight of the project for me was not just the valuable findings that came out of 80 interviews with young people, which are research outputs of their own brilliantly managed by Alicia (which you can read for free here), but the process of co-producing research with patient experts and carers. I have discussed the idea of co-production a bit in my own digital technology and sexuality research, in which I (loosely) explored the co-production by both researcher and participant of a safe discursive space for covering sensitive topics in sex and sexuality in fieldwork research (which you can read for free here). But This Sickle Cell Life made co-production central from the start and throughout the full four years of the project; it is clear to me only now how truly different this way of working is, and the value it adds.

Attendees at the participatory dissemination event for This Sickle Cell Life (Photo: Anne Koerber)

The winding road to publication: How expertise is framed in academia

What was interesting was how our co-produced research outputs were received by peer reviewers for academic journals. Having learnt so much from our patient experts about how their experiences reflected what our results showed us about participants’ experiences, we invited them to write an academic article with us. We did this by discussing study findings with them and inviting them to discuss these themes with us as I took notes and recordings to write into a larger discussion. It was a long process, involving lots of conversations in cafes, on the phone and by email to coordinate our different experiences and expertise.

However, upon submission several reviewers critiqued what they felt to be overly personal accounts of sickle cell. Even having noted our co-produced efforts and celebrated this ethos, reviewers still picked out patient expert passages that they felt were lacking objective research – questioning the expertise of our co-production partners who were best placed to be reflecting on the study findings. Where our patient experts told us how their experiences chimed with those of the participants when it came to hospital care or chronic ill health or family issues, and I wove these reflections into our discussion section, reviewers felt this expertise was anecdotal or somehow unscientific – as if the rest of the qualitative dataset was by contrast unobjectionable or markedly positivist, when of course it wasn’t. We were in the paradoxical position of amplifying the expert knowledge of people with sickle cell and yet that knowledge being somehow too ‘real-life’.

We were in the paradoxical position of amplifying the expert knowledge of people with sickle cell and yet that knowledge was somehow too ‘real-life’.

I have sympathy for the reviewers, too, because despite the best will of a whole range of actors to more actively incorporate a range of knowledges into academic publications, establishment traditions prevail. This clashes with what I guess I would call the out-of-place-ness of equitable authorship, which synthesises a range of voices, including those which are non-establishment and may contribute in different (often refreshingly different) ways than are standard. None of this is to say that it wasn’t a valuable experience, but it was a long one. Critical Public Health and its editors did support our approach, with suggestions back and forth, and published what we hope will be the first of several co-produced articles (read it for free here).

Screen Shot 2020-04-06 at 14.19.19

That leads us to one of the curious tensions in this kind of work – our collaborators are clearly experts, but they’re not academics. Does that matter? Well, it shouldn’t – especially given the UK NHS drive to centre patients and public at the forefront of research and healthcare involvement. And yet the process of publishing papers with our patient experts was not straightforward. It required different ways of working than what we were all used to, and different approaches – and that’s before we consider the lengthy journey we then had publishing our co-produced academic article, where roadblocks re-emerged.

I came to see that the key contribution of any author is their contribution to ‘the work’, and this can go far beyond typing up results or making an argument for changing UK healthcare practices in an academic article. Instead, it is about having conversations – in ways that ensure equity between all parties – and then using academics’ toolkits to package this co-produced knowledge whilst maintaining its integrity. For us, a more liberatory outcome would have been yet more unconventional than the finished piece. Maybe this would have taken us further from what makes an academic article an academic article. Well, you might argue, if you really want to publish more collaboratively, perhaps a different format would be better suited – a commentary, or an editorial, or a blog – and we are in the process of doing all those things. But this argument overlooks the ostensible openness of academic publishing to co-produced and public involvement endeavours. We’re all supposed to be embracing that ethos…aren’t we? There is work to do, it seems, in lining up expectations with conventions in co-produced research outputs.

Workshopping involvement at This Sickle Cell Life participatory dissemination event (Photo: Anne Koerber)

Final thoughts

As for the research itself, it’s been a fantastically valuable project for better understanding the health and social conditions of sickle cell. There are definitely ways we can further improve on our approaches to co-production for next time. It’s also not to say that our co-production work was straightforward or easy. On the contrary, it required constant communication between all parties to stay on the same page. But that ongoing relationship, and that time taken to gather views from around the table really ought to be how we always operate: with care, consideration and dialogue between all parties at all times. We came to define it as ‘slow co-production’, which I’ve blogged about before (we lay out what we think are its strengths in this article). It is only within the tight parameters of contemporary academic research contracts that this valuable, lengthy process feels like a luxury. I should add that the NIHR were very supportive of our approach and helped us build into our budget money to support exactly this kind of process, and they also gave us a generous timeframe in which to generate all this co-produced work.

It also encourages us to question what constitutes ‘knowledge’, who or what entities ‘hold’ knowledge (and you see it performed nowhere more starkly than in healthcare settings), and of the power imbalance between researcher and participant. Now I think twice before internalising the status quo of privilege and position in knowledge-holding (and knowledge exchange). I think more about how practical experience informs knowledge – or is overlooked by systems of knowledge and knowing – and who actually gets a seat at the table in supposedly collaborative endeavours. Cicely and Alicia have written about all of this and more, and you can read this work here, here and here.

Pursuing co-production helps us recognise the importance of prioritising equitable social science research that values all voices equally and recognises a range of expertise, rather than relying on the (often colonial, socially-structured, privileged) expertise bestowed – and often still prioritised – by academia.

Some of the This Sickle Cell Life collaborators (Top row L-R: Patrick Ojeer, Ganesh Sathyamoorthy, Sam Miles, Nordia Willis, Alicia Renedo, Andrea Leigh. Bottom row L-R: Cicely Marston, John James, Siann Millanaise. Photo: Anne Koerber)

This Sickle Cell Life was funded by the National Institute for Health Research Health Services and Delivery Research Programme (project number 13/54/25). The views and opinions expressed therein are those of the author and do not necessarily reflect those of the HS&DR Programme, NIHR, NHS or the Department of Health.

Oh, What Do You Do To Me? the City says to Tinder

Happy new year! We are welcoming back our readers with this new blogpost by DEPTH researcher Sam Miles, who was recently invited to be interviewed about sex, technology and cities for the Urban Political podcast. Read on to find out how it came about… 

Sam: As well as working with my DEPTH colleagues here at LSHTM on sexual and reproductive health and rights (SRHR) for marginalised populations, and on the voices and experiences of young people with sickle cell, I have for a while now researched the relationship between sex and sexualities, digital technologies, and space. It’s work that I started for my PhD in 2013 and every year the themes it throws up feel even more relevant – how people find social or sexual relationships, how personal safety operates online and offline, what community means for LGBT+ people, and how we integrate (or don’t integrate) technologies into our daily lives.

I was recently invited by The {Urban Political} podcast to give an interview on dating apps and urban geographies. The {Urban Political} produces podcasts on ‘contemporary urban issues with activists, scholars and policy-makers’ that aim to advance our understanding of urban environments and how we might make them more democratic. They wanted to discuss my research on the relations between online dating apps and the production of urban space, especially with regards to sex and sexualities. I said yes because I was so intrigued by the questions presenter Dr Markus Kip posed:

Do apps like Grindr and Tinder make the city a more loving place? Do they make dating more safe for women or trans people? And do they cohere greater acceptance of queer cultures, or the opposite?

These are important questions. When put to you by someone not in your head, as it were, they have the helpful effect of sharpening focus on what is really at stake when it comes to the reality (and future) of digital technology and the welfare of sexual minorities.

People’s lived experiences are important. Thinking about the consequences of changing physical environments through the use of dating and hook-up apps beyond simplistic readings of ‘good’ and ‘bad’ offers us a real opportunity to think critically about what these platforms mean not just for individual users, but more widely for society, community and geopolitics.

urban politicalThat’s not all: in the podcast we also discuss what app companies do with the data that users provide (whether willingly or unknowingly), and what ethical boundaries are being tested in this kind of data sharing – as well as the ethics of app use itself. I’ve argued before that locative media technologies have grown at such a rapid pace that mutually-agreed social codes for use are yet to catch up with the development of these sophisticated platforms, which can lead to clashing expectations between users. I believe these (perfectly valid) tensions will be replicated and amplified across a wide range of social networks and ‘smart’ technologies in the near future as digital technologies become progressively more integrated into our daily lives.

As for the question ‘what needs to happen at an individual, collective or technological level to make online dating more useful or pleasant?’, there are any number of answers, and for me none of them are definitive. It’s become clear over recent years that dating apps are not an alternative utopian world, free from the ugliness of ‘real’ life – numerous reports of racism (special mention for #KindrGrindr), femmephobia and fat-shaming on just Grindr alone exemplify exactly that. But maybe there is space for a future of sociality, solidarity and support for sexual minorities who network online. We already see these kinds of networks in action in queer organising, online communities, and support groups at various scales and in various guises. There is no reason why dating and hook-up apps cannot similarly be collectively co-opted to embrace more ‘promiscuous’ socialisation to combat loneliness, more political solidarity with a range of queer identities and livelihoods, and more support for sexual rights agendas, whether they be PrEP provision or sexual & reproductive health rights. We can make it a 2020 resolution, can’t we?

You can listen to the podcast here, and check out other Urban Political podcasts here. There’s plenty to choose from, from the Hong Kong protests to heritage vs. gentrification.

This article was adapted from Sam’s blog post on Sexuality & the city.

Let’s talk about sex

How do researchers go about interviewing people about sex and sexualities? To what extent do we – or should we – share our own experiences? And what kind of ‘spaces’ do these highly personal conversations fit into?

DEPTH researcher Dr Sam Miles was invited by the academic journal Area to write a blog for their outreach website Geography Directions, based on his recent article ‘“I’ve never told anyone this before”: Co‐constructing intimacy in sex and sexualities research’. In the blog, Sam explores the ethics of fieldwork in sex and sexualities research. Have a read… 

The (in)famous male-male dating and hook-up app Grindr recently celebrated its 10th birthday. To mark the anniversary, a whole range of articles have cropped up variously celebrating and lamenting Grindr’s influence across the world (by which I mean literally across the world – it counts nearly 4 million active users across 234 different countries (Grindr, 2019)). What makes this generation of mobile phone matchmakers different from the online platforms that went before them, for example Gaydar, match.com, Yahoo chatrooms? Apps such as Grindr are GPS-enabled, which enables users to ‘rank’ other users of the app by proximity, ensuring that potential matches can be discovered and introduced in real-time across physical space.

Reflecting on Grindr’s first decade, The BBC identifies a ‘rocky relationship’, whilst VICE magazine explores Grindr’s relationship with identity fraud and drug-based ‘chemsex’; meanwhile, Gay Times reports that 56% of Grindr users believe they can find true love on the app. Whatever your opinion on it – and there are many – there is no doubt that this mobile phone matchmaker, along with its competitors Hornet, Scruff & Jack’d, has had a profound impact on gay and bisexual communities. These apps have also opened up new avenues for men seeking sex with men (MSM) who for whatever reason – familial, cultural, or religious – do not identify as gay or bisexual.

Grindr Stock image

The bigger question raised by these recent articles seems to be: how do dating and hook-up apps impact on same-sex and queer relationships today? This question cannot be answered by quantitative usage data alone. After all, we know that high usage does not necessarily mean high popularity. We need to explore peoples’ real life experiences in order to more fully understand the impact of dating and hook-up apps on same-sex and queer relationships.

I decided that the best way to get a detailed understanding of how these apps influence sexual and social behaviours would be to interview users about their experiences online, offline, and in the ‘hybrid’ space bridging the two, where virtual introductions result in real-life encounters. My doctoral research revealed some important findings: (1) that dating and hook-up apps play a significant role in how men now meet other men, especially within wider debates about the ‘death of the gay bar’, and (2) that the relationship between mobile phone dating app users and the people they meet can be awkward, with social cues yet to catch up to the sophistication of the technologies in use.

The sensitive nature of the research topic meant that there was an array of ethical and practical challenges for me to grapple with during my doctoral fieldwork. In my recent Area paper, I reflect on some of these challenges and explore how researchers and participants can work together to create a meaningful space that not only enables data collection, but facilitates honest and valuable conversation. I consider what the researcher’s responsibility should be for a participant’s safety in this discursive space. I also reflect on how ‘involved’ I should be as a researcher. I’m a person, not a robot, and several decades of feminist research has already explored the strengths and issues bound up in bringing ‘yourself’ into the research field (for example, see Bain & Nash (2006) and Smith (2016)). But the opposite extreme of the objective, positivist robot researcher is the inappropriately involved one, a role which would be both institutionally unethical and personally unacceptable. I therefore identified my own boundaries as well as the participants’s boundaries. The result was a co-constructed discursive space that we worked together to construct, perhaps surprisingly, in totally public venues and in one-off, hour-long interviews rather than more private or longer-term meetings. These were not ‘intimate’ spaces in a traditional sense, but nevertheless the space-within-a-space that we constructed invited app users to speak about highly personal experiences, some for the first time ever.

I also make the case for the using public places for staging sensitive conversations. The assumption that private matters cannot be discussed in public requires a rethink. Public spaces like libraries or cafes enfold within them more private spaces – not just actual booths or nooks, although these can contribute – but I’m thinking here about more conceptual spaces. These are built simply via one-to-one, in-person conversation in a space where a hubbub of background talking, or the hiss of coffee machines brewing, provides a backdrop to conversation that can be very productive.

Finally, when it comes to dating and hook-up apps in particular, I suggest that people are particularly keen to share their views because the social norms of dating app use are so complex and still so poorly understood. For lots of people online dating remains taboo. In this context, the chance to share their thoughts, feelings and experiences when it came to the digitally-introduced, physically-involved relationships these platforms offer may have been liberating.

Love dating apps or hate them (or both), what I hope the article communicates is that we need to talk more with users about the ways in which technologies impact on our personal lives, in order to think about the social codes developing from their use that will inform a whole range of wider contexts.

What do you think? Let us know by commenting below…

References:

Bain, A., & Nash, C. (2006) Undressing the researcher: Feminism, embodiment and sexuality at a queer bathhouse event. Area, 38, 99–106. https://rgs-ibg.onlinelibrary.wiley.com/doi/pdf/10.1111/j.1475-4762.2006.00663.x

Damshenas, S. (2019) 56% of Grindr users believe they can find love on the app, study finds. Gay Times. Retrieved from: https://www.gaytimes.co.uk/community/119691/56-of-grindr-users-believe-they-can-find-love-on-the-app-study-finds/

Fox, L. (2019) 10 years of Grindr: A rocky relationship. BBC News. Retrieved from: https://www.bbc.co.uk/news/technology-47668951

Grindr. (2019) Grindr.com. Retrieved from: https://www.grindr.com/

Miles, S. (2017) Sex in the digital city: location-based dating apps and queer urban life. Gender, Place & Culture, 24, 1595-1610: https://www.tandfonline.com/doi/abs/10.1080/0966369X.2017.1340874?tab=permissions&scroll=top

Miles, S. (2018) Still getting it on online: Thirty years of queer male spaces brokered through digital technologies. Geography Compass. e12407. ISSN 1749-8198 DOI: https://doi.org/10.1111/gec3.12407

Miles, S. (2019) “I’ve never told anyone this before”: Co‐constructing intimacy in sex and sexualities research. AREA. https://rgs-ibg.onlinelibrary.wiley.com/doi/full/10.1111/area.12550

Smith, S. (2016) Intimacy and angst in the field. Gender, Place & Culture, 23, 134–146.

Staples, L. (2019) Grindr Users Talk Highs and Lows After Ten Years of the App. VICE Magazine. Retrieved from: https://www.vice.com/en_us/article/59x83d/grindr-users-talks-highs-and-lows-after-ten-years-of-the-app-1

Still getting it on online

Our latest blog is by Dr Sam Miles, who discusses the recent publication of his academic article ‘Still getting it on online: Thirty years of queer male spaces brokered through digital technologies’ in the journal Geography Compass.

By way of introduction, I thought I’d borrow from my latest article to give you a snapshot of what I’ll be talking about in this blog post:

I call on contemporary scholarship to demonstrate how [mobile phone] platforms offer a way into answering larger cultural questions about cruising, queer social life, and space. I conclude that these locative digital media occupy a distinctive position in the history of queer technologies and signal a shift in how gay male online spaces are both conceptualised and experienced.

In the social sciences, theories of sex and sexuality have long been tied up in ideas of space and place. There are any number of examples we can think of, from the spaces of sex work and how these spaces are regulated or policed, to the rise (and more recently, fall) of the commercialised ‘gay village’ in the global north, which is often discussed in terms of its relations with economics and gentrification. 

Trying to better understand the relationship between sex and sexuality and space is important because beyond theoretical ideas, it has an impact on how a location might influence sexual identity, practices or safety. For example, healthcare interventions for sex workers might depend on a safe space accessible from their working space. Civil rights demonstrations or an LGBTQ pride parade in a repressive political environment can be read as a temporary ‘queering’ of the orthodoxy or regime by making space for sexual difference in streets normally controlled by the mainstream.

My own research has focused on digital technology and sexual practices. I have been interviewing ‘MSM’ (men who have sex with men, including but not limited to gay and bisexual men) to learn more about how recent developments in technology mean that queer male space is not just physical, but virtual too.

 Geography Compass invited me to write an article for them reviewing the history of queer male online space. I think this topic is particularly fascinating is because the social sciences have long tracked physical queer spaces, and this research is widely known; less is known about how online platforms contribute to producing or re-making queer spaces. What I specialise in is locative media – by which I mean GPS enabled mobile phone apps – that are now very popular amongst MSM to network and meet others for social and/or sexual connection. These locative apps include Tinder, Grindr and Hornet, and have a huge user base around the world. Grindr alone counts nearly 4 million users per day.

I argue that the development of mobile internet over the past decade, and the GPS abilities that are now built into even basic smartphones, strongly influence how men meet other men for relationships and sex. This in turn has an impact on ‘offline’ LGBTQ venues such as gay bars or cruising sites, as well as traditional understandings of ‘queer community’ and what that might mean. As I write in the article:

Male–male locative media can strengthen and extend social‐sexual networks, facilitating meetings with like‐minded men across a borough, district, or city. This is especially true among the users for whom a queer community is out of reach because of their isolation, whether familial, social, or geographical.

Of course, being connected to other sexual minorities through an app does not automatically constitute a community, but some users do report a sense of like-mindedness, even if this does not match up with the more established ways in which we define community.

Beyond MSM populations specifically, this idea of technology redefining community, whether for better or worse (or indeed both!) is crucial to how we understand how technology mediates human behaviour. In a public health context, technology needs to be harnessed in ways which are alert to local conditions, whether that is in terms of unequal access to technology, or an affinity (or restriction) to certain kinds of communication device. At the same time, the widespread adoption of mobile phone technology – 5 billion people worldwide now have access to mobile phones – shows that digital technology ‘on the go’ will become ever more central to daily life. The job now is to extend research carried out on mobile digital technologies and sexualities to different populations to help us understand more about how these platforms will impact on social and sexual practices in the near and distant future.

You can read Sam’s article here and follow him on Twitter here.

Sickle Cell, Sociology, Scotland: Report-back from the BSA Medical Sociology conference

What is the legacy of medical sociology? How has it shaped other disciplines and practices? And what is its role in challenging the status quo of inequalities in health?

These were some of the topics discussed by very talented people at this year’s MedSoc (Medical Sociology) Conference in Glasgow. These were also some of the issues that drove our aim to explore how transitions to adulthood for young people with sickle cell could be improved and how healthcare services could help support these. The conference provided a great opportunity to present our sickle cell research.

Our presentation focused on how health transitions shape the identities of young people and how this contributes to the ways in which young people develop into adult patients. Transitions to adulthood can often bring challenges, and for young people with sickle cell, the challenges often faced in education, social and emotional transitions to adulthood are complicated by their condition, and they must navigate these complex changes as well as changes in their hospital care that can bring problems as they move from child to adult health services.

There was a range of interesting presentations to choose from. Martyn Pickersgill’s fascinating talk about the dialectic between patient experience and diagnostic practice, resonated with some of our findings on the hybridisation of knowledge through the dialogue between ‘subjective’ patient experiences and ‘objective’ evidence. Charlotte Kühlbrandt’s ethnographic paper helped to shed light on the intricate relationship between citizenship/non-citizenship and patienthood/non-patienthood in the context of Roma Health Mediation in Romania. In this case, health mediation becomes correction in the production of normative forms of citizens and patients. In our case, we showed how healthcare transitions become self-disciplining ‘at a distance’ and form part of a relentless process of self-governance through which young people try to become the types of patient and citizens they ought to be.

Eva Krockow made us think about how we balance the individual versus collective good when we make choices about antibiotic prescribing.

 

The panel plenary, with a focus on inequalities, was fascinating. The keynote papers from Professor Ellen Annandale discussed the ‘gendering’ of health inequalities and the embodiment of global gender power relations such as the health consequences of biogenetic trade. Professor Hannah Bradby pointed out barriers faced by forced migrants across Europe, the stratification of migrant status and how this interacts with “acceptable” forms of vulnerability.  Some migrants find themselves having to amplify and enact their vulnerability (mental health) to access care and citizenship status. Professor Graham Scambler’s keynote paper on “What’s Left of Class for medical sociology?” encouraged discussion about our role as sociologist activists in challenging health inequalities.

With Scambler’s call to action, I left the conference eager to continue my commitment to medical sociology and critical engagement with inequalities in health. You can keep up to date with our work in these areas via our website, DEPTH twitter account and our This Sickle Cell Life project twitter account.

Presenting at the forthcoming BSA Medical Sociology Annual Conference

Last week, we headed to Glasgow for the BSA Medical Sociology Annual Conference to share a sneak preview of our findings from This Sickle Cell Life: voices and experiences of young people with sickle cell.

Sickle cell disease is a genetic blood disorder disproportionately found in minority ethnic communities in Britain. It is a chronic debilitating condition that both causes cumulative damage to multiple organ systems, and causes acute pain.

This Sickle Cell Life is part of the work of DEPTH research group at LSHTM. The project explores how people move from using child to adult healthcare services and asks young people about their experiences of living with sickle cell. Transitioning to adulthood is obviously not just something that affects clinical experiences and so we also explore education and relationships, and ask young people what is important to them.

At the BSA MedSoc conference we talked about how healthcare transitions shape the identity of young people, and how these transitions help ‘make’ particular kinds of patients.

Why focus on identity? Health transitions need new health knowledge and new behaviours to develop, but they also need development of self-perceptions and understandings of how a person should behave as an adult (rather than a child) patient. In this way, identities play an important role in shaping health practices and beliefs. Understanding identity development during transitions can help explain why some young people transition smoothly or less smoothly into healthy adulthood.

In our presentation, we talked about how ideas and discourses about self-management and healthy lifestyle within healthcare today act as a way to discipline young people “at a distance”, to quote Miller & Rose (1990) and influence their behaviour. These healthcare self-management discourses intersect with demands from schools that are often not compatible. For instance, schools demand that young people excel and become entrepreneurial, competent individuals, but excelling at school is far more difficult for young people who have to spend time in hospital, or who have to rest regularly to avoid having a pain crisis. These intersecting demands can translate into conflicting “self-disciplining” identities.

For young people with sickle cell, we found that transitions to adulthood involve relentless self-disciplining and self-surveillance to try to be as healthy as possible, while also aspiring to work hard so that they can develop and meet educational and career goals.

You can check back on our updates from the BSA conference on the Sickle Cell LifeTwitter account, here.

A whistle-stop tour of the DEPTH research group at LSHTM

Now that you’ve been introduced to our new blog, we thought it would make sense to give you a whistle-stop tour of our DEPTH research group here at LSHTM.

We are a group of scholars in the Department of Public Health, Environments and Society at London School of Hygiene & Tropical Medicine who take an interdisciplinary approach to health. We are one of LSHTM’s newest hubs, developed earlier this year as a way to bring together some of our shared work. We use the acronym DEPTH to unify our themes of Dialogue, Evidence, Participation and Translation for Health. We conduct research into different types of dialogue and different people’s participation in health with the aim of increasing equity and improving health worldwide, and amplifying less-heard voices.

Our new website has allowed us to introduce a wider audience to our public health work – you can check it out here. We see it as a space for communication and conversation – not just with academic colleagues, but also in policy debates, in education systems and with the wider public. We also think it is important to show our work to a wide range of audiences, not just specialists, and so we have listed all of our individual or combined efforts on this page, including summaries of each research paper listed in plain English, with concepts summarised and acronyms explained. You can read about the six Research themes that underpin DEPTH here. These research themes include our work on patient and public involvement, dialogues about sexual and reproductive health and young people’s experiences of Sickle Cell, and our work with Imperial College London on the ethics of electronic health records.

As for this blog, it functions as a conversation space. It provides a way for us to write about important studies in the field of community involvement, participation and public health. We will talk about our own research, but will also write about current affairs as well as research from elsewhere, when we would like to contribute to debate. We agree that one of the most important things we can do as academics is move beyond our own research specialisms to listen to – and amplify – the perspectives of those who may be less heard. We hope you will find these perspectives as valuable as we do – and key to this is conversation.

Finally, we want to hear from you too! Our blog now has comment space, and we’re very keen to hear your views, thoughts and ideas. You can get also get involved via our Twitter account, and you can contact us with questions, feedback or even your own blog pitch. Finally, look out for upcoming events on this blog page, where we will post details of future talks, meetings and events, as well as commentaries on new publications and policy.

Thanks again for reading and we look forward to sharing more about our work at DEPTH.

Sam, Research Fellow, DEPTH.

Welcome to our DEPTH research blog

 

Hello readers,

Welcome to our DEPTH research blog here at LSHTM. DEPTH stands for Dialogue, Evidence, Participation and Translation for Health. We are a research hub in the Public Health & Policy faculty of London School of Hygiene & Tropical Medicine. The research hub is made up of LSHTM staff members Cicely Marston, Alicia Renedo, Catherine McGowan and Sam Miles, along with doctoral researchers who you can read more about here.

We’ve recently developed our own website, including academic publications, updates and links to our research areas including This Sickle Cell Life, sixteen18 and patient & public engagement. To ensure maximum interaction with readers, we have made this WordPress website to allow (indeed, to positively encourage!) reader comments. We feel that this is a crucial part of our work. We see our blog as a space for communication and conversation – not just with academic colleagues, but also in policy debates, in education systems and with the wider public.

Welcome in!