a wide range of evidence for the effectiveness of midrange critical theory, cultural ecology, and risk reduction. These range from more theoretical constructions to models for application of the theories (Singer 1995; Singer et al. 2006), and the politics of HIV research (Singer 1994). Cultural disparities-oriented studies have successfully applied these theories to institutional environments impacting social justice issues (cf. Trotter et al. 2019).
In addition, the direct observation of behaviors to determine the impact of the environment on behavior constitutes a primary methodology for health ecological studies. Some of these studies have targeted the results of prevention or behavioral change programs and culturally competent interventions in risk taking behavior. A linked series of studies of needle sharing and needle hygiene practices supported by the National Institute on Drug Abuse exemplifies midrange theory combined with observational methods in a cultural ecological context. The component studies of this project focus on context specific uses of injection equipment among drug users in the United States, as part of HIV risk reduction efforts for drug injectors. Descriptive observations in this realm (Koester 1994; Page 1990; Page et al. 1990) explore both the meaning and the processes of injection drug use, needle sharing, and the public health consequences of drug paraphernalia laws (laws that restrict the possession of syringes that might be used for drug abuse). Later studies (Clatts et al. 1996; Singer et al. 1995) explore the micro-environmental consequences of needle hygiene and needle sharing in depth. One example of the latter approach is the Needle Hygiene Project, conducted by the National Institutes on Drug abuse Cooperative Agreement Program (Needle et al ND, Koester 1994). These studies have led to changes in the recommended messages and training processes for HIV risk reduction among injection drug users.
On a population health level, multidisciplinary teams have also used cultural–ecological models to address risks, and potential prevention activities associated with environmental contaminants. There is considerable interest, and resources available, to identify and mitigate health disparities in underserved populations, and there are a growing number of trans-disciplinary protocols to achieve that goal. (Trotter et al. 2019).
Cross-cultural Applicability Midrange Theory and Methods
One of the most obvious and most practical midrange theories in medical anthropology is the theory of cultural relativity. It is also one of the most miss-applied and politically misused theories in anthropology. This theory is an expression of the empirical findings of anthropologists and other social scientists that groups tend to share consensual world views within the group, and differentiate those world views from others outside the group. Finding examples, from folk medicine to health care prevention programs, is easy, but the findings also frequently result in highly complex actions and recommendations (from calls for cultural competency, to representations that only members of the same culture, or social strata, or language group, or gender, or lifestyle orientation, etc. can understand X culture and therefore can be sufficiently culturally competent to deal with the health and medically related problems of that culture). These forms of cultural particularism tend to reinforce difference at the expense of the possibility for cross-cultural understanding and action. At the same time, the “one size fits all” universalism found in some health interventions is based on a view that constantly stumbles over social and cultural difference, to the detriment of understanding the actual confluence of culture, health, healing and medicine in peoples everyday lives.
One example of a successful applied medical anthropology project in this arena of work is the revision of an international classification of disabilities, the ICIDH CAR2 study. The study had to satisfy 12 data needs in relation to both the ICIDH revision process: (1) identify linguistic equivalencies for conceptual transfer of elements of the classification into local languages and back to English; (2) explore the cultural contexts, practices, and values concerning disablements in the local culture; (3) investigate whether the proposed structure of the classification has good cross-cultural stability; (4) conduct an item-by-item evaluation of the cross-cultural applicability of each facet of the classification; (5) explore alternative models for the classification; (6) collect data on the parity or lack of parity in accommodation and level of stigma between mental health and physical disablements; (7) collect data on the boundaries between the three levels of the: classification system; (8) establish information on the thresholds that apply to disablements (when someone is considered disabled and when are they not shows significant cultural variability); (9) investigate information on stigma attached to various types of disablements; (10) produce a description of the current programs and need for programs that serves populations with disabilities; (11) compare the relative importance of different types of disabling conditions in different cultures; and (12) create a general description of the place and meaning of disabilities and disability programs in local cultures. The practical aspects of the design required conducting the research at a number of different centers around the world that have varying levels of experience with qualitative and quantitative research methods. The methods had to be easy to use, inexpensive, comprehensive, and capable of producing defensible results. The ICIDH CAR model was designed to address a consistent issue for multisite cross-cultural applied research. The research requires a standardized sampling framework that does not place an extreme burden on the various centers. We used qualitative sampling procedures for the bulk of the CAR study, except in those cases where statistical power needs dictated a quantitative sampling approach. The ethnographic sampling framework was comprised of selected individuals who were especially knowledgeable about their culture, rather than randomly selected individuals who might not be able to contribute substantively to the study (cf. Johnson 1990a,b; Schensul et al. 1999). The process appropriately differs from probabilistic (forms of random) sampling due to the goals of the study, especially the need to interview individuals who are cultural experts and who have substantive knowledge in the area of disablement. The final results of the study and application was a consensual, multi-national, revision of the old disabilities classification system into a new system for assessing functioning in cultural context, which is a significant paradigm shift for both WHO and the disabilities communities. (Ustun et al. 2001).
Rapid Assessment as a Methodological Framework: Combining Emergent Theory, Midrange Theory, and Systematic Ethnographic Design
One of the highest impact methodological innovations in applied medical anthropology is the development of systematic rapid ethnographic methods and techniques targeted at emerging public health problems. This approach has been used to respond to problems such as malaria, diarrheal disease, dengue, breast and bottle feeding, and now drug abuse, AIDS and disaster relief. Rapid assessment was first formally described in the mid-1980s (Bentley et al. 1988; Schrimshaw et al.1987 ; Schrimshaw et al. 1991) along with other rapid assessment and evaluation models developed about the same time. Rapid ethnographic assessment fits into the general model of rapid assessment paradigms, including those used for rapid environmental appraisal (Oliver and Beattie 1996; Stohlgren et al. 1997), rapid epidemiology (Anker 1991; Smith 1989), rapid disaster assessment (Malilay et al. 1997), and rapid assessment of biomedical conditions (Lee and Price 1995). Rapid ethnographic assessment has a well-documented history of success in both international and domestic contexts (e.g., Dale et al. 1996; Vlassoff and Tanner 1992). It has been used in developing countries as a substitute for survey and other quantitative data-collection processes and as a compliment to existing data sets and surveillance systems. Examples include research about malaria in the Philippines (Miguel et al. 1999), HIV among young people in Cambodia (Tarr and Aggleton 1999), family planning in Burkina Faso (Askew et al. 1993), preschool children exposed to pesticides in Mexico (Guillette et al. 1998), sexually transmitted disease and HIV prevention in Turkey (Aral and Fransen 1995), and injection drug use in Vietnam (Power 1996). Rapid assessment is also used as a complimentary data collection process in developed countries. In this role, it is seen as valuable in targeting conditions and contexts that are more highly concentrated than those identified by normal surveillance and epidemiological efforts. It provides information for spotting emerging conditions that are not yet visible in other data sets and allows for the development of interventions successfully configured for local contexts, especially where local cultural conditions and values differ from the dominant cultural system. Examples of these types of rapid
