Lisa Fitzgerald

A qualitative study on the acceptability and preference of three types of long-lasting insecticide-treated bed nets in Solomon Islands: implications for malaria elimination

BackgroundIn March 2008, the Solomon Islands and Vanuatu governments raised the goal of their National Malaria Programmes from control to elimination. Vector control measures, such as indoor residual spraying (IRS) and long-lasting insecticidal bed nets (LLINs) are key integral components of this programme. Compliance with these interventions is dependent on their acceptability and on the socio-cultural context of the local population. These factors need to be investigated locally prior to programme implementation.MethodTwelve focus group discussions (FGDs) were carried out in Malaita and Temotu Provinces, Solomon Islands in 2008. These discussions explored user perceptions of acceptability and preference for three brands of long-lasting insecticide-treated bed nets (LLINs) and identified a number of barriers to their proper and consistent use.ResultsMosquito nuisance and perceived threat of malaria were the main determinants of bed net use. Knowledge of malaria and the means to prevent it were not sufficient to guarantee compliance with LLIN use. Factors such as climate, work and evening social activities impact on the use of bed nets, particularly in men. LLIN acceptability plays a varying role in compliance with their use in villages involved in this study. Participants in areas of reported high and year round mosquito nuisance and perceived threat of malaria reported LLIN use regardless of any reported unfavourable characteristics. Those in areas of low or seasonal mosquito nuisance were more likely to describe the unfavourable characteristics of LLINs as reasons for their intermittent or non-compliance. The main criterion for LLIN brand acceptability was effectiveness in preventing mosquito bites and malaria. Discussions highlighted considerable confusion around LLIN care and washing which may be impacting on their effectiveness and reducing their acceptability in Solomon Islands.ConclusionProviding LLINs that are acceptable will be more important for improving compliance in areas of low or seasonal mosquito nuisance and malaria transmission. The implications of these findings on malaria elimination in Solomon Islands are discussed.

‘When you come to it you feel like a dork asking a guy to put a condom on’: is sex education addressing young people's understandings of risk?

Traditionally, school‐based sex education has provided information‐based programmes, with the assumption that young people make rational decisions with regard to the use of condoms. However, these programmes fail to take into account contextual issues and developing subjectivities. This paper presents the talk of 42 young people from a New Zealand secondary school who were questioned in‐depth about the sex education programme they had received. They discussed a programme that concentrated on the ‘dangers’ and ‘risks’ of sexual intercourse and that failed to enhance negotiation skills or take into account the contexts in which sex occurred for many young people. Although participants were well aware of the public health discourses of the importance of condom use, the implications of putting these discourses into practice held the potential for ‘risks’ of a greater magnitude in the reality of their everyday life. The ‘risk’ to reputation and subjectivity overrode any ‘risks’ that may have occurred through non‐use of condoms. This highlights the need for sex education programmes to put greater effort into developing skills of assertiveness, communication and empowerment.

The Impact of Decriminalisation on the Number of Sex Workers in New Zealand

In 2003, New Zealand decriminalised sex work through the enactment of the Prostitution Reform Act. Many opponents to this legislation predicted that there would be increasing numbers of people entering sex work, especially in the street-based sector. The debates within the New Zealand media following the legislation were predominantly moralistic and there were calls for the recriminalisation of the street-based sector. This study estimated the number of sex workers post-decriminalisation in five locations in New Zealand: the three main cities in which sex work takes place as well as two smaller cities. These estimations were compared to existing estimations prior to and at the time of decriminalisation. The research suggests that the Prostitution Reform Act has had little impact on the number of people working in the sex industry.

Community participation for malaria elimination in tafea province, vanuatu: part ii. social and cultural aspects of treatment-seeking behaviour

BackgroundEarly diagnosis and prompt effective case management are important components of any malaria elimination strategy. Tafea Province, Vanuatu has a rich history of traditional practices and beliefs, which have been integrated with missionary efforts and the introduction of modern constructions of health. Gaining a detailed knowledge of community perceptions of malarial symptomatology and treatment-seeking behaviours is essential in guiding effective community participation strategies for malaria control and elimination.MethodAn ethnographic study involving nine focus group discussions (FGD), 12 key informant interviews (KII) and seven participatory workshops were carried out on Tanna Island, Vanuatu. Villages in areas of high and low malaria transmission risk were selected. Four ni-Vanuatu research officers, including two from Tanna, were trained and employed to conduct the research. Data underwent thematic analysis to examine treatment-seeking behaviour and community perceptions of malaria.ResultsMalaria was perceived to be a serious, but relatively new condition, and in most communities, identified as being apparent only after independence in 1980. Severe fever in the presence of other key symptoms triggered a diagnosis of malaria by individuals. Use of traditional or home practices was common: perceived vulnerability of patient and previous experience with malaria impacted on the time taken to seek treatment at a health facility. Barriers to health care access and reasons for delay in care-seeking included the availability of health worker and poor community infrastructure.ConclusionDue to programme success of achieving low malaria transmission, Tafea province has been identified for elimination of malaria by 2012 in the Government of Vanuatu Malaria Action Plans (MAP). An effective malaria elimination programme requires interactions between the community and its leaders, malaria workers and health providers for success in diagnosis and prompt treatment. As malaria becomes more uncommon, utilizing unique motivators for communities to seek early diagnosis and treatment is important, particularly as other health conditions that cause fevers become increasingly more common. The design of these interventions are dependent upon robust understanding of community perceptions of disease, and the evolving nature of these perceptions.

Now we are in a different time; various bad diseases have come. Understanding men's acceptability of male circumcision for HIV prevention in a moderate prevalence setting.

BackgroundAdult male surgical circumcision (MC) has been shown to reduce HIV acquisition in men and is recommended by the WHO for inclusion in comprehensive national HIV prevention programs in high prevalence settings. Only limited research to date has been conducted in countries experiencing moderate burden epidemics, where the acceptability, operational feasibility and potential epidemiological impact of MC remain unclear.MethodsA multi-method qualitative research study was conducted at four sites in Papua New Guinea (PNG), with 24 focus group discussions and 65 in-depth interviews carried out among 276 men.ResultsThe majority of men were in favour of MC being introduced for HIV prevention in PNG and considered improved genital hygiene, enhanced sexual pleasure and culturally appropriateness key factors in the acceptability of a future intervention. A minority of men were against the introduction of MC, primarily due to concerns regarding sexual risk compensation and that the intervention went against prevailing cultural and religious beliefs.ConclusionThis is one of the first community-based MC acceptability studies conducted in a moderate prevalence setting outside of Africa. Research findings from this study suggest that a future MC program for HIV prevention would be widely accepted by men in PNG.

More than just a cut: a qualitative study of penile practices and their relationship to masculinity, sexuality and contagion and their implications for HIV prevention in Papua New Guinea

BackgroundMale circumcision (MC) has been shown to reduce vaginal transmission of HIV to men. While community acceptability is important in a countries preparedness to introduce MC, it is equally important to map contemporary MC and other penile cutting practices, and the socio-cultural dimensions underpinning these practices.MethodsA total of 482 men and women (n = 276 and n = 210, respectively) participated in 82 semi-structured and 45 focus group discussions from four different provinces of Papua New Guinea (PNG), each representing one of the four socially and geographically diverse regions of the country.ResultsOf the men interviewed 131 self-reported that they had undergone a penile alteration with some reporting multiple types. Practices were diverse and could be grouped into five broad categories: traditional (customary) penile cutting; contemporary penile cutting; medical circumcision; penile inserts; and penile bloodletting practices in which sharp objects are used to incise the glans and or inserted and withdrawn from the male urethra or in order to induce bleeding. Socio-cultural traditions, enhanced sexual pleasure and improved genital hygiene were key motivators for all forms of penile practices.ConclusionsThe findings from this study highlight the complex and diverse nature of penile practices in PNG and their association with notions of masculinity, sexuality and contagion. Contemporary penile practices are critical to a community’s acceptance of MC and of a country’s ability to successfully implement MC in the context of a rich and dynamic culture of penile practices. If a MC program were to be successfully rolled out in PNG to prevent HIV it would need to work within and build upon these diverse cultural meanings and motivators for penile practices already commonly performed in PNG by men.

On a fast-track into adulthood: an exploration of transitions into adulthood for street-based sex workers in New Zealand

There have been many debates in the literature about the extended transition to adulthood many young people are experiencing in late modern times. However, not all young people make this prolonged transition and, for some, resources within their family and community networks are insufficient to enable an extended transition into stable, independent adult roles. The findings presented in this paper are drawn from a large participatory research project investigating the impact of decriminalisation on the health and safety practices of sex workers in New Zealand. This paper utilises the talk of 17 street-based sex workers who entered the industry under the age of 18 years, as well as using data from a survey of 772 sex workers in New Zealand. For young people entering the industry prior to the age of 18, the period of adolescence was short-lived and their inability to gain support through either their family or the government meant that they opted to work in the sex industry to survive. Unsupported transitions into adulthood are characterised by a high degree of risk with limited employment options. This research highlights the need for policy-makers to develop holistic, multi-sectorial policies for young people which are not based on age-specific frameworks.

Factors impacting HIV testing: a review – perspectives from Australia, Canada, and the UK

With the current global focus on strengthening HIV prevention through greater testing and treatment uptake, it is increasingly salient to identify and address barriers to testing. A review of the published, peer-reviewed literature and national reports from Australia, Canada, and the UK (2003–2013) on barriers to HIV testing was conducted to provide new information relevant to Australia and to complement earlier reviews from Canada and the UK. A systematic database search using keywords and a set of inclusion criteria yielded 36 studies (Australia = 13; Canada = 6; and the UK = 17). In addition 17 unpublished reports were included in the review. Our study uses a novel, comprehensive framework to describe barriers to HIV testing, and thus contributes to moving beyond the traditional patient–provider–system categorization. Within that framework, barriers are categorized as either intrapersonal (reported in 15 studies), interpersonal (21), or extrapersonal (16) and conceptualized within wider sociocultural and structural contexts. Peoples abilities and motivations to test (intrapersonal factors) are influenced by a host of interconnected factors spanning relationship (interpersonal) and broader socioeconomic, political and cultural (extrapersonal) factors. We suggest that the relative effects of interventions targeting barriers to HIV testing at the intrapersonal and interpersonal levels are limited by the extent to which the social determinants of health are addressed. The framework may also lend itself to thinking about the enabling factors for HIV testing, and future research may investigate the application of that framework for strategizing the most effective response. Future studies should also capture the lived experiences of barriers to HIV testing experienced by patients, especially in populations which are hard to reach based on social and geographic distance. Context-specific studies to evaluate the feasibility and effectiveness of various interventions proposed in the literature to address barriers to HIV testing are needed.

Factors associated with antiretroviral treatment uptake and adherence: a review. Perspectives from Australia, Canada, and the United Kingdom

ABSTRACT International focus on reducing onward HIV transmission emphasizes the need for routine HIV testing and early uptake of antiretroviral treatment (ART). Strategic targets have been set for 2020 to achieve the goal of 90% of people infected with HIV diagnosed, 90% of identified cases on treatment, and 90% of persons on treatment virally suppressed (90–90–90). It is vital to understand the complexity of factors influencing a persons treatment decisions over time and the context which may enable better adherence. In this paper we present findings from the review of published and gray literature (2003–2013) on the documented factors associated with treatment initiation and adherence in the general adult population of Australia, Canada, and the UK. A framework developed by Begley, McLaws, Ross, and Gold [2008. Cognitive and behavioural correlates of non-adherence to HIV anti-retroviral therapy: Theoretical and practical insight for clinical psychology and health psychology. Clinical Psychologist, 12(1), 9–17] in Australia was adapted to summarize the findings. A systematic database search using keywords and a set of inclusion criteria yielded 17 studies (Australia = 6; Canada = 8; UK = 3). In addition 11 reports were included in the review. We found that a persons abilities and motivations (intrapersonal factors, reported in 7 studies) to start and continue ART are influenced by a host of interconnected factors spanning relationship (interpersonal, 3 studies) and broader structural (extrapersonal, 15 studies) factors that are situated within social determinants of health. People therefore evaluate various costs and benefits of starting and staying on treatment, in which biomedical concerns play an important yet often subsidiary role. In this review the economic barriers to care were found to be significant and under-reported, highlighting the persistent health inequities in terms of access to services. Our understanding of the context around peoples use of ART remains poor. Qualitative social research within HIV-positive communities is urgently needed to capture peoples lived experiences and may address some of this deficit in understanding.

‘The street's got its advantages’: Movement between sectors of the sex industry in a decriminalised environment

This article explores the movement of sex workers between sectors of the sex industry in New Zealands decriminalised environment and motivations for working in these different venues. We argue for contextual, risk environment approaches to understanding risks associated with the different sectors and how these risks might influence the movement of sex workers between sectors. By doing so we also address arguments made by policy makers in different countries, with different ways of regulating sex work, for the eradication of the street-based sector of the sex industry. The findings are drawn from a survey of 772 sex workers and in-depth qualitative interviews with 58 sex workers in New Zealand. Findings suggest there is a growing private sector but little change in the size of the street-based sector following decriminalisation. Street-based sex workers argue the need to maximise earnings and that this is only possible from the street environment. They are prepared to make the trade-off of more money for less safety, something which managed sex workers are not prepared to do. This article demonstrates the relativity of risk perceptions and concludes that attempts to eradicate the street-based sector of the sex industry through more stringent regulatory practices are unrealistic and will only serve to place this vulnerable segment of the sex worker population at greater risk. It argues that in addition to decriminalisation, other social and economic policies are required to address risk and develop more enabling environments within the diverse sectors of the sex industry.