A potential HIV epidemic among male street laborers in urban Vietnam

Background: Mass migration to Asian cities is a defining phenomenon of the present age, as hundreds of millions of people move from rural areas or between cities in search of economic prosperity. Although many do prosper, large numbers of people experience significant social disadvantage. This is especially the case among poorly educated, migrant unskilled unregistered male laborers who do much of the manual work throughout the cities. These men are at significant risk for many health problems, including HIV infection. However, to date there has been little research in developing countries to explain the determinants of this risk, and thereby to suggest feasible preventive strategies. Objectives and Methodology: Using combined qualitative and quantitative methods, the aim of this study was to explore the social contexts that affect health vulnerabilities and to develop conceptual models to predict risk behaviors for HIV [illicit drug use, unsafe sex, and non-testing for HIV] among male street laborers in Hanoi, Vietnam. Qualitative Research: Sixteen qualitative interviews revealed a complex variety of life experiences, beliefs and knowledge deficits that render these mostly poor and minimally educated men vulnerable to health problems including HIV infection. This study formed a conceptual model of numerous stressors related to migrants’ life experiences in urban space, including physical, financial and social factors. A wide range of coping strategies were adopted to deal with stressors – including problem-focused coping (PFC) and emotion-focused coping (EFC), pro-social and anti-social, active and passive. These men reported difficulty in coping with stressors because they had weak social networks and lacked support from formal systems. A second conceptual model emerged that highlighted equivalent influences of individual psychological factors, social integration, social barriers, and accessibility regarding drug use and sexual risk behavior. Psychological dimensions such as tedium, distress, fatalism and revenge, were important. There were strong effects of collective decision-making and fear of social isolation on shaping risk behaviors. These exploratory qualitative interviews helped to develop a culturally appropriate instrument for the quantitative survey and informed theoretical models of the factors that affect risk behaviors for HIV infection. Quantitative Research: The Information-Motivation-Behavioral Skills (IMB) model was adopted as the theoretical framework for a large-scale survey. It was modified to suit the contexts of these Vietnamese men. By doing a social mapping technique, 450 male street laborers were interviewed in Hanoi, Vietnam. The survey revealed that the risk of acquiring and transmitting HIV was high among these men. One in every 12 men reported homosexual or bisexual behavior. These men on average had 3 partners within the preceding year, and condom use was inconsistent. One third had had sex with commercial sex workers (CSW) and only 30% of them reported condom use; 17% used illicit drugs sometimes, with 66.7% of them frequently sharing injecting equipment with peers. Despite the risks, only 19.8% of men had been tested for HIV during the previous 12 months. These men have limited HIV knowledge and only moderate motivation and perceived behavioral skills for protective behavior. Although rural-to-urban migration was not associated with sexual risk behavior, three elements of the IMB model and depression associated with the process of mobility were significant determinants of sexual behavior. A modified model that incorporated IMB elements and psychosocial stress was found to be a better fit than the original IMB model alone in predicting protected sex behavior among the men. Men who were less psychologically and socially stressed, better informed and motivated for HIV prevention were more likely to demonstrate behavioral skills, and in turn were more likely to engage in safer sexual behavior. With regard to drug use, although the conventional model accounted for slightly less variance than the modified IMB model, data were of better fit for the conventional model. Multivariate analyses revealed that men who originated from urban areas, those who were homo- or bi-sexually identified and had better knowledge and skills for HIV prevention were more likely to access HIV testing, while men who had more sexual partners and those who did not use a condom for sex with CSW were least likely to take a test. The modified IMB model provided a better fit than the conventional model, as it explained a greater variance in HIV testing. Conclusions and Implications: This research helps to highlight a potential hidden HIV epidemic among street male, unskilled, unregistered laborers. This group has multiple vulnerabilities to HIV infection through both their partners and peers. However, most do not know their HIV status and have limited knowledge about preventing infection. This is the first application of a modified IMB model of risk behaviors for HIV such as drug use, condom use, and uptake of HIV testing to research with male street laborers in urban settings. The study demonstrated that while the extended IMB model had better fit than the conventional version in explaining the behaviors of safe sex and HIV testing, it was not so for drug use. The results provide interesting directions for future research and suggest ways to effectively design intervention strategies. The findings should shed light on culturally appropriate HIV preventive education and support programs for these men. As Vietnam has much in common with other developing countries in Southeast Asia, this research provides evidence for policy and practice that may be useful for public health systems in similar countries.

Dancing Diseases : an applied theatre response to the challenge of conveying emotionally contradictory messages in HIV education

Health educators face an unusual challenge in relation to HIV: the need to convey two emotionally contradictory messages. On the one hand, there is currently no cure for HIV, which eventually leads to death (emotionally negative message). On the other hand, people with HIV can live long, healthy and productive lives (emotionally positive message). In developing countries where HIV prevalence is high, it is imperative that both messages are conveyed effectively. This article reports on a specific form, Dancing Diseases, implemented as one component of the Life Drama pilot study on Karkar Island, Papua New Guinea. Life Drama is an applied theatre and performance approach to HIV education. The article discusses Dancing Diseases as an example of applied theatre and performance practice, reflects on the participant group’s engagement with the form, and offers some ways in which the form could be refined and used in other health education contexts.

Risks for HIV infection among male street laborers in urban Vietnam

Risks for HIV infection remain unknown in male street laborers. This research investigates patterns of self-reported risk behaviors among these men in urban Vietnam. In a cross-sectional survey using a social mapping technique, 450 men, mostly low-skilled and unregistered migrant laborers across 13 districts in Hanoi were approached for interviews. The study revealed that male street laborers were at high risk of acquiring and transmitting HIV. One in every 12 men reported homosexual or bisexual behavior. These men on average had three sexual partners within the preceding year, and condom use was inconsistent. Close to 95 % of the men had reported sexual encounters with regular partners. One-third with commercial sex workers (CSW) and 24.2 % with casual partners, but just under one-third had ever used condoms with regular partners and CSWs and very few (17.6 %) with casual partners at their last sexual encounter. 17.11 % used illicit drugs sometimes, with 66.7 % of them frequently sharing injecting equipment with peers. These men had limited HIV knowledge; 51.4 % incorrectly believed that, once you trust your partner, you no longer need to use condoms and 42.4 % believed that you can tell by looking at someone if they have HIV. Access to HIV prevention was also limited; only 19.8 % of men had been tested for HIV during the previous 12 months, almost 10 % of whom neither returned for the result nor knew their HIV status. The study provides interesting directions for future research and suggests ways to effectively design prevention strategies for these men.

Evolution of life drama program

Life Drama is a program of drama-based experiential learning activities involving groups of community leaders and members. The three-year project evolved from a theatre-in-education approach to an intercultural theatre approach incorporating Papua New Guinean performance traditions. It involved Australian, English and Papua New Guinean researchers at four key sites: Tari, Southern Highlands Province; Port Moresby, National Capital District; Madang, Madang Province; and Karkar Island, Madang Province. The project was innovative in a number of ways, including: a Participatory Action Research approach, involving community leaders at various levels as co-researchers; a participatory theatre approach as opposed to a performance approach; emphasis on sexual health promotion and HIV prevention through an experiential learning paradigm; addressing the norms and realities of the community rather than targeting only individual behaviour; an International Theatre Research Laboratory to explore the fusion of traditional cultural elements with contemporary health promotion aims; and an innovative method-assemblage approach to collecting and triangulating quantitative, qualitative, and performative data. The project attracted over $350,000 in funding and support from the Australian Research Council, National AIDS Secretariat in PNG, and private sector and non-government partners. Findings were presented at various conferences and symposia including the annual Medical Symposium in Wewak (2010), the triennial Research in Drama Education conference in Exeter (2011), and the International Research in Drama Education conference (Sydney 2009 and Limerick 2012). A number of peer-reviewed journal articles have been published. Elements of the program have been incorporated into the University of Goroka's compulsory HIV awareness program for undergraduate students. A national dissemination strategy for Life Drama in Papua New Guinea is now underway, with seed funding of AUD$74,000 from the National AIDS Council Secretariat, PNG.

Life Drama Papua New Guinea : contextualising practice

This article presents the Life Drama project as a case study in how theoretical and contextual factors may inform the development of an applied theatre initiative. Life Drama is a workshop-based, participatory form of applied theatre and performance being developed in Papua New Guinea. At this time, the aim of Life Drama is to address the gap between ‘awareness’and behaviour change in relation to sexual health, particularly HIV. The paper situates Life Drama within three fields of theory and practice – applied theatre, theatre for development and HIVeducation – and critically reflects on the ways in which this program is attempting to meet key challenges identified in the literatures of these fields.

Folk opera : stories crossing borders in Papua New Guinea

The Life Drama project is a drama-based sexual health promotion project, developed by a cross-cultural research team in Papua New Guinea (PNG) over the past four years. Recognising the limitations of established theatre-in-education and theatre-for-development approaches when working across cultures, the research team explored ways of tapping into the everyday performativity of PNG participants and their communities in order to communicate more powerfully about the personal and social issues involved in sexual health. Through the Folk Opera form, developed by PNG theatre company Raun Raun Theatre around the time of national Independence, the research explored the importance of ‘story’ in identity formation, maintenance and change, the communication of meaning, and the transmission of tacit local knowledges. In a highly diverse and rapidly-changing country like PNG, enacted stories inherently compel the exchange and exploration of different knowledges, and promote the dialogue and ownership that drives social change. The paper will present and unpack the folk opera form as developed in the Life Drama program, drawing conclusions which may apply to other programs which to promote health and social justice across cultures.

Folk opera : stories crossing borders in Papua New Guinea

The Life Drama project is a drama-based sexual health promotion project, developed by a cross-cultural research team in Papua New Guinea (PNG) over the past four years. Recognising the limitations of established theatre-in-education and theatre-for-development approaches when working across cultures, the research team explored ways of tapping into the everyday performativity of PNG participants and their communities in order to communicate more powerfully about the personal and social issues involved in sexual health. Through the Folk Opera form, developed by PNG theatre company Raun Raun Theatre around the time of national Independence, the research explored the importance of "story" in identity formation, maintenance and change, the communication of meaning, and the transmission of tacit local knowledges. In a highly diverse and rapidly-changing country like PNG, enacted stories inherently compel the exchange and exploration of different knowledges, and promote the dialogue and ownership that drives social change. The paper will present and unpack the Folk Opera form as developed in the Life Drama program, drawing conclusions which may apply to other programs which to promote health and social justice across cultures.

Modeling predictors of risky drug use behavior among male street laborers in urban Vietnam

Background The application of theoretical frameworks for modeling predictors of drug risk among male street laborers remains limited. The objective of this study was to test a modified version of the IMB (Information-Motivation-Behavioral Skills Model), which includes psychosocial stress, and compare this modified version with the original IMB model in terms of goodness-of-fit to predict risky drug use behavior among this population. Methods In a cross-sectional study, social mapping technique was conducted to recruit 450 male street laborers from 135 street venues across 13 districts of Hanoi city, Vietnam, for face-to-face interviews. Structural equation modeling (SEM) was used to analyze data from interviews. Results Overall measures of fit via SEM indicated that the original IMB model provided a better fit to the data than the modified version. Although the former model was able to predict a lesser variance than the latter (55% vs. 62%), it was of better fit. The findings suggest that men who are better informed and motivated for HIV prevention are more likely to report higher behavioral skills, which, in turn, are less likely to be engaged in risky drug use behavior. Conclusions This was the first application of the modified IMB model for drug use in men who were unskilled, unregistered laborers in urban settings. An AIDS prevention program for these men should not only distribute information and enhance motivations for HIV prevention, but consider interventions that could improve self-efficacy for preventing HIV infection. Future public health research and action may also consider broader factors such as structural social capital and social policy to alter the conditions that drive risky drug use among these men.

Predictors of condom use behaviour among male street labourers in urban Vietnam using a modified Information-Motivation-Behavioral Skills (IMB) model

HIV risk in vulnerable groups such as itinerant male street labourers is often examined via a focus on individual determinants. This study provides a test of a modified Information-Motivation-Behavioral Skills (IMB) model to predict condom use behaviour among male street workers in urban Vietnam. In a cross-sectional survey using a social mapping technique, 450 male street labourers from 13 districts of Hanoi, Vietnam were recruited and interviewed. Collected data were first examined for completeness; structural equation modelling was then employed to test the model fit. Condoms were used inconsistently by many of these men, and usage varied in relation to a number of factors. A modified IMB model had a better fit than the original IMB model in predicting condom use behaviour. This modified model accounted for 49% of the variance, versus 10% by the original version. In the modified model, the influence of psychosocial factors was moderately high, whilst the influence of HIV prevention information, motivation and perceived behavioural skills was moderately low, explaining in part the limited level of condom use behaviour. This study provides insights into social factors that should be taken into account in public health planning to promote safer sexual behaviour among Asian male street labourers.

From 'what' to 'how' : capacity building in health promotion for HIV/AIDS prevention in the Solomon Islands

This paper describes a capacity building process undertaken within the HIV/AIDS prevention project of the Adventist Development and Relief Agency (ADRA) in the Solomon Islands. ADRA HIV/AIDS has recently reoriented its project structure, moving beyond its awareness raising approach to incorporate health promotion frameworks, theories, strategies and assumptions. These have been used to inform project practice in project planning, delivery and evaluation. This paper shares what has worked and not worked in the capacity building process, including a project evaluation of the initial HIV/AIDS awareness raising project and the application of a number of capacity building strategies, including utilising a volunteer Australian Youth Ambassador for Development (AYAD) funded by the Australian Agency for International Development (AusAID). Existing and new projects are outlined. The underlying theme is that any capacity building exercise must include structural support (e.g. management, national frameworks) to ensure the incorporation of new initiatives and approaches. With time this enables ownership by counterparts and external partnerships to develop. The presence of an AYAD volunteer has been an effective strategy to achieve this. Reflections from the evaluators, the AYAD volunteer and the HIV/AIDS team are included.

Treatment for prevention of HIV transmission in a localised epidemic : the case for South Australia

Background: Discussion is currently taking place among international HIV/AIDS groups around increasing HIV testing and initiating earlier use of antiretroviral therapy (ART) among people diagnosed with HIV as a method to reduce the spread of HIV. In this study, we explore the expected epidemiological impact of this strategy in a small population in which HIV transmission is predominantly confined to men who have sex with men (MSM). Methods: A deterministic mathematical transmission model was constructed to investigate the impacts of strategies that increase testing and treatment rates, and their likely potential to mitigate HIV epidemics among MSM. Our novel model distinguishes men in the population who are more easily accessible to prevention campaigns through engagement with the gay community from men who are not. This model is applied to the population of MSM in South Australia. Results: Our model-based findings suggest that increasing testing rates alone will have minimal impact on reducing the expected number of infections compared to current conditions. However, in combination with increases in treatment coverage, this strategy could lead to a 59–68% reduction in the number of HIV infections over the next 5 years. Targeting men who are socially engaged with the gay community would result in the majority of potential reductions in incidence, with only minor improvements possible by reaching all other MSM. Conclusions: Investing in strategies that will achieve higher coverage and earlier initiation of treatment to reduce infectiousness of HIV-infected individuals could be an effective strategy for reducing incidence in a population of MSM.

Suicidal ideation, suicide attempts, and HIV infection

A cross-sectional study was performed to investigate the prevalence and predictors of suicidal ideation and past suicide attempt in an Australian sample of human imumunodeficiency virus (HIV)-positive and HIV-negative homosexual and bisexual men. Sixty-five HIV-negative and 164 HIV-positive men participated. A suicidal ideation score was derived from using five items selected from the Beck Depression Inventory and the General Health Questionnaire (28-item version). Lifetime and current prevalence rates of psychiatric disorder were evaluated with the Diagnostic Interview Schedule Version-III-R. The HIV-positive (Centers for Disease Control and Prevention [CDC] Stage IV) men (n=85) had significantly higher total suicidal ideation scores than the asymptomatic HIV-positive men (CDC Stage II/III) (n=79) and the HIV-negative men. High rates of past suicide attempt were detected in the HIV-negative (29%) and HIV-positive men (21%). Factors associated with suicidal ideation included being HIV-positive, the presence of current psychiatric disorder, higher neuroticism scores, external locus of control, and current unemployment. In the HIV-positive group analyzed separately, higher suicidal ideation was discriminated by the adjustment to HIV diagnosis (greater hopelessness and lower fighting spirit), disease factors (greater number of current acquired immunodeficiency syndrome [AIDS]-related conditions), and background variables (neuroticism). Significant predictors of a past attempted suicide were a positive lifetime history of psychiatric disorder (particularly depression diagnoses), a lifetime history of injection drug use, and a family history of suicide attempts. The findings indicate increased levels of suicidal ideation in symptomatic HIV-positive men and highlight the role that multiple psychosocial factors associated with suicidal ideation and attempted suicide play in this population.

A test of the job demands : resources model with HIV/AIDS volunteers

Burnout has been identified as a significant factor in HIV/AIDS volunteering. It has been associated with depression, anxiety and the loss of volunteers from the health care delivery system. The aim of this study was to test the independence of the health and motivational processes hypothesized within the Job Demands – Resources model of burnout in HIV/AIDS volunteers. Participants were 307 HIV/AIDS volunteers from state AIDS Councils throughout Australia who completed self-report measures pertaining to role ambiguity and role conflict, social support, burnout, intrinsic and organizational satisfaction, and depression. Findings suggested that the independence of the dual processes hypothesized by the model was only partially supported. These findings provide a model for burnout which gives a framework for interventions at both the individual and organizational level which would contribute to the prevention of burnout, depression, and job dissatisfaction in HIV/AIDS volunteers.