Authors: Sheba Mohammid and Daniel Miller

Open access image by Volodymyr Hryshchenko.

Right now, Trinidad and Tobago are suffering amongst the highest death rate from Covid in the world. As small islands, everyone seems to know people who have died. According to a Trinidadian doctor specialising in this field one reason for this is co-morbidity with diabetes, obesity and hypertension. Diabetes is also the leading co-morbidity factor in Europe^[1]. These are exactly the health conditions our final ASSA project in Trinidad is focusing on. Yet we would estimate perhaps half the population is resistant to getting the Covid vaccination, either not having it (48.3%), or being vaccinated only because of pressure, such as keeping their job. In response Sheba Mohammid has focused on researching the reasons people remain opposed to vaccination even in such tragic circumstance, as part of her online ethnographic in Trinidad.

The first thing that became clear in Sheba’s investigations was a fundamental problem with research on this topic. She began, as most researchers would, by asking the people concerned. People gave her many reasons for not being vaccinated, but it soon became obvious that when one reason no longer applied, the emphasis was shifted to another. For example, a person might say they didn’t want AstraZeneca and were waiting for Pfizer. But when Pfizer came along, they give an entirely different reason based on some nurses not being vaccinated. It gradually became clear that what people say in answer to this question is based on the pressure to legitimate their actions. The way these various forms of rationale are replaceable suggests that a deeper investigation was required.

The second stage of her research then tried to focus on two main issues that had developed as possibly the core underlying reasons for taking this stance, using additional evidence from their wider discussions and concerns. The first is general fear and mistrust that the vaccine might itself make one ill. The second was a general resistance to top-down assertions that the facts were clear and that they should take the vaccine. Indeed, it is likely that a response such as fact-checking would only harden the resolve to resist those people from above who cannot be trusted and keep insisting that only their facts were the true facts. By contrast, the stories that made them more fearful of vaccination came not from government, but from people more like themselves. Yet it was also clear that this opposition to authority was different from other regions. The people in Trinidad did not call themselves anti-vaxx or associate with US opposition movements to the vaccine about which they were well informed.

The third stage, began with a realisation that these oppositions may have deeper roots that relate more to local cultural values. The US movement is a more organised opposition reflecting the current degree of politicisation in the US. Danny’s conversations with people in Ireland suggest that an important factor there is the degree of personal support that people opposed to vaccination give each other in the community. Trinidad turns out to have its own quite specific reasons for opposing the vaccine, less political than the US and more individualised than Ireland for opposing the vaccine. In each region      there are deeper resonances that may account for the local resistance.

The traditional relationship in Trinidad between health and the body is not a culture of preventative medicine but rather “If it eh broken, why fix it.” Healthcare is often framed as problem-solving medical intervention that seeks to ease the consequences of an illness and is a last resort. Medicine then is largely framed as curative and many people recount how they avoid health tests saying that they “have one life to live and doh want to know,” but will only seek medical care as a treatment if they feel all else has failed and they are now willing to go to the doctor for help. Indeed, patients may then complain when a doctor merely gives them a painkiller that they could get over the counter  since they expect a special injection. But otherwise, in deeper discussion and sustained participant observation as to why people have not taken the vaccine, they insist that `Ah Good’ – basically they are feeling fine and they fully intend to remain feeling fine. So, at that stage why take a risk by being injected with something that at least some other people are saying, especially on circulating social media, that will itself harm your health.

Sheba interviewed doctors regarding diabetes and hypertension who regularly underscored that a main challenge is this lack of preventative healthcare that is in fact a key challenge to the health system. This idea of “being good” intersected with the insights she gleaned on how people refuse to take high blood sugar or pressure seriously if on the surface they seem fine and thus the proliferation of these “silent killers” in the population.  She found that it was the norm that if participants were taking something to keep healthy it should be a natural food or substance that has no associations at all with becoming ill and seem to pose no risk. This meant that an illness which has an asymptomatic phase such as Covid19 would be particularly devastating, because as long as people feel good, they are confident that they cannot be a danger to others or contract it themselves if they spend time with people who seem asymptomatic. In the meantime, it is taking the vaccine that represents risk, not the failure to have taken it. Appearance matters and there is considerable stress on showing to others that one is healthy, while even talking about ill health and medicines ‘kills the vibe’ and should be avoided unless one is actually ill. This study also showed us that our original plans for helping to improve diet in relation to diabetes would probably not have worked, at least in this context, and a different approach is now being considered.

Clearly these generalisations only apply to some of this population. But it may be an important underlying part of the culture surrounding the body and health. Extrapolating from this conclusion, it would seem that research based simply on asking people for their reasons for not taking the Covid vaccination, or worse still projecting upon them one’s assumptions, are not likely to be helpful. A more anthropological insistence on taking vaccine hesitancy seriously and finding the deep roots that sustain it in people’s values and wider attitudes may be required for each region of concern.

^[1] Corona. G. et. al 2021 Diabetes is most important cause for mortality in COVID-19 hospitalized patients: Systematic review and meta-analysis Rev Endocr Metab Disord Jun;22(2):275-296.

doi: 10.1007/s11154-021-09630-8.

By Daniel Miller and Sheba Mohammid

Open access image CC BY Liftarn

The ASSA project runs until October 2022. Mostly the last year of the project is dedicated to publishing our results, for example The Global Smartphone has now come out in Spanish and Italian, and the monographs from Ireland and Italy are also published. There is also a continuation of applied work such as Charlotte Hawkins’ contribution to a tele-psychiatry project in Uganda. But there is also one final ethnographic project. This is being carried out in Trinidad by Sheba Mohammid with the support of Danny. Sheba is very suited to this work having written her PhD on how Trinidadians use YouTube. As a final project this is more oriented towards completing the trajectory of our mHealth research. The story so far is that the ASSA project began with the intention of studying mHealth apps for smartphones. Over time as we realised older people make very little use of these bespoke apps, the project shifted to the study of how people turn the apps they are comfortable with into health apps, for example, WhatsApp, LINE and WeChat, but also Google and YouTube. For example, Marilia Duque’s manual on the use of WhatsApp for health in Brazil demonstrates how what we learn from the everyday practices of our research participants can then be used to inform others. In Trinidad we are hoping within a one-year project to research smartphone usage, plan and implement an mHealth intervention, and evaluate it – though that is quite ambitious in the limited time period.

The Trinidad project is progressing well and it looks like the emphasis will be on issues of diet in relation to diabetes, hypertension and also concerns over anxiety… we shall see. After three months, however, something quite different has emerged that is worth reporting on. Early on in the pandemic Danny shared a YouTube video on how to conduct ethnography with only online access. Given the stringent covid controls in Trinidad, online methods have been the only way we could conduct our ethnography. The good news was that, at least in this instance, the optimism of that YouTube video has been vindicated. Sheba’s work certainly amounts to conventional ethnography. As well as interviews, she has regularly spent periods of three or four hours online with her research participants, hanging out and chatting about all manner of things.

Sheba conducting ethnography online. Photo by Sheba Mohammid.

The online ethnography has focused upon building relationships, as is aspires to in traditional ethnography, and from this foundation trying to attain greater insight into the practices of participants and the wider ecosystem of social connections in which these are situated. Besides some in-depth formal interviews with participants, Sheba regularly spent time cultivating a better understanding and appreciation of their everyday lives. Participants have spent time with their webcam on, hanging out with her while they attended to childcare, cooking, breastfeeding, arranging appointments on the phone or dealing with the daily minutiae in between their chats. The success of the online ethnography so far has depended on Sheba being flexible and determined to follow up, send reminders and work around participants and their evolving schedules and internet problems etc. More than anything, Sheba has prioritised sensitivity and a privileging of their well-being in a time when it was not uncommon to have participants dealing with Covid19 related deaths in their households, their own infections or economic fallout from job loss and insecurity during the pandemic.

As participants grew closer to Sheba and more interested in our study, a deeper intimacy emerged where participants became eager to share more information and would send her WhatsApp screenshots of interesting feedback they received on their apps or new social media accounts on diet and fitness that they thought she might be interested in. All of this amounted to an ongoing, sustained conversation over the last few months with many participants and an engagement in their lives that buttressed the formal interviews on mobile phones and health with participant observation on their everyday lives. For example, after an interview, a participant may take her phone outside to demonstrate to Sheba how she had been setting up her kitchen garden. There were constraints that Sheba had to work around and be adaptive to in the online fieldwork. For example, she felt that it was often intrusive to ask people to show her their phone screens to look at conversations in the way that then team had done in the past in in-person fieldwork. Sheba instead adapted this method by exploring other opportunities within the online interactions. She was able to go online with participants and look at social media together to gain their perspectives. For example, she would have them walk her through which YouTube fitness accounts they preferred or which Instagram or TikTok influencers they found appealing and why or why not. She followed where this ethnography took her and ended up talking to some key Trinidadian social media influencers that participants pointed out as noteworthy. Many of Sheba’s participants were recruited through recommendations and participants asking their family and friends to talk to her. While she initially used some of her own networks in Trinidad to source participants, she then worked to extend her fieldwork to include a diverse range of participants.

The online ethnography over the past three months has enabled Sheba to gain greater access into a broad demographic of participants in both rural and urban Trinidad and from a broad cross-section of ethnic and socio-economic backgrounds. This was achieved largely through participants themselves helping her to recruit more and more participants. For example, one woman in her 60s living in Port of Spain who worked in a retail store introduced her and shared WhatsApp contacts with the members of her AquaAerobics group or when Sheba was trying to recruit more male participants, a female participant linked her online through WhatsApp to her nephew who helped her get more contacts to further male participants and so on in a true snowballing manner that has taken place through online ethnographic work. This recruitment has only been incentivised through participants deepening their relationship with Sheba and gaining an enthusiastic interest in the project and wanting to see us succeed in collecting meaningful data and translating that into something applied next year. So more on that to come in 2022. It will no doubt be a challenge but it is heartening so far to have been able to create such a supportive network of participants, many of whom are interested in being involved in the applied work so we can achieve our aim of creating something from the bottom up.

Happy New Year from Danny and Sheba!

Stay tuned for more…