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.

Unpacking the micro-macro nexus: narratives of suffering and hope among refugees from Burma recently settled in Australia

Narratives of forced migration are open to a variety of interpretations. In mental health, refugee narratives of arduous journeys in the face of systemic macro socio-political forces are often transformed from this context into a medicalized micro context of inner individual worlds. Both the dominant pathogenic lens of trauma studies and the growing salutogenic lens embodied in resilience research, often reflect a western cultural idiom of focusing on the individualized nature of these phenomena. Using qualitative data collected from refugees from Burma now settling in Australia, the article emphasizes the need for a more reflexive and expansive account of both suffering and hope within refugee narratives. It recounts these narratives within a conceptual framework which acknowledges the importance of the connections between the micro individual experience and the macro, socio-political context. This is not only a question of political principle, but also a matter of listening to the voice of those who know most about the relationship between macro forces of human rights violations and their impact on individual, family and community trajectories.

Refugees : the Millenium Development Goals' overlooked priority group

The Millennium Development Goals (MDGs) apply to the world’s 43 million refugees and forcibly displaced. While States have an obligation to meet minimum human rights levels for all persons including 'non-citizens', UNHCR must ensure countries adopting MDG targets report on the progress of their refugee populations. If we are to make significant change within the MDG time-frame, the health and human rights needs of refugees and the displaced must be urgently integrated into the development policy agendas of sovereign States, and be at the fore of the international community’s attention.

Ageing out of place: health and well-being needs and access to home and aged care services for recently arrived older refugees in Melbourne, Australia

Recently arrived older refugees in resettlement countries are a particularly vulnerable population who face many risks to their health and well-being, and many challenges in accessing services.This paper reports on a project undertaken in Victoria,Australia to explore the needs of older people from 14 recently arrived refugee communities, and the barriers to their receiving health and aged care. Findings from consultations with community workers and service providers highlight the key issues of isolation, family conflict and mental illness affecting older refugees, and point to ways in which policy-makers and service providers can better respond to these small but deserving communities.

Examining the health related quality of life of people with end stage kidney disease living in Hanoi, Vietnam

Background: The prevalence of end-stage kidney disease (ESKD) patients is increasing in Vietnam; however, the impact of ESKD and its treatment on a person’s quality of life (QOL) is not well understood. Objective: This research sought to examine the association between monthly income, comorbidity, length of time on dialysis, social support and health-related quality of life (HRQOL) among Vietnamese ESKD patients. Method: Using a descriptive design, 95 patients who were receiving haemodialysis (HD) and peritoneal dialysis (PD) from one hospital in Hanoi, were conveniently sampled. Results: ESKD patients reported having a moderate level of HRQOL. Factors associated with QOL were social support (r= .268, p<.05), comorbid health conditions (r= –.185, p<.05), and length of time on dialysis (r= .182, p<.05). However, monthly income was not significantly related to HRQOL (p>.05). Conclusion: The results seem to indicate that ESKD patients in Vietnam have a high level of support from family members, friends and significant others. There was also a negative impact of comorbid conditions on the QOL of these patients. Based on the results of this study, nurses ought to develop nursing interventions which will lead to a better QOL for patients, and further research into the QOL for ESKD patients in Vietnam is warranted.

A longitudinal study of mental health in refugees from Burma : the impact of therapeutic interventions

Objective: The present study seeks to examine the impact of therapeutic interventions for people from refugee backgrounds within a naturalistic setting. Method: Sixty-two refugees from Burma were assessed soon after arriving in Australia. All participants received standard interventions provided by a resettlement organisation which included therapeutic interventions, assessment, social assistance, and referrals where appropriate. At the completion of service provision a follow-up assessment was conducted. Results: Over the course of the intervention, participants experienced a significant decrease in symptoms of post-traumatic stress disorder, anxiety, depression and somatisation. Pre-intervention symptoms predicted symptoms post-intervention for post-traumatic stress, anxiety, and somatisation. Post-migration living difficulties, the number of traumas experienced, and the number of contacts with the service agency were unrelated to all mental health outcomes. Conclusions: In the first Australian study of its kind, reductions in mental health symptoms post-intervention were significantly linked to pre-intervention symptomatology and the number of therapy sessions predicted post-intervention symptoms of post-traumatic stress. Future studies need to include larger samples and control groups to verify findings.

The Multidimensional Loss Scale : validating a cross cultural instrument for measuring loss in Burmese refugees

The Multidimensional Loss Scale: Initial Development and Psychometric Evaluation The Multidimensional Loss Scale (MLS) represents the first instrument designed specifically to measure loss in refugee populations. Researchers developed initial items of the Multidimensional Loss Scale to assess Experience of Loss Events and Loss Distress in a culturally sensitive manner across multiple domains (social, material, intra-personal and cultural). A sample of 70 recently settled Burmese adult refugees completed a battery of questionnaires, including new scale items. Analyses explored the scale’s factor structure, internal consistency, convergent validity and divergent validity. Principal Axis Factoring supported a five-factor model: Loss of Symbolic Self, Loss of Interdependence, Loss of Home, Interpersonal Loss, and Loss of Intrapersonal Integrity. Chronbach’s Alphas indicated satisfactory internal consistency for Experience of Loss Events (.85) and Loss Distress (.92). Convergent and divergent validity of Loss Distress were supported by moderate correlations with interpersonal grief and trauma symptoms and weak correlations with depression and anxiety. The new scale was well received by people from refugee backgrounds and shows promise for application in future research and practice

Socio-structural influences on the work participation of refugees : an exploratory systematic mixed studies review

This systematic mixed studies review aimed at synthesizing evidence from studies related to the influences on the work participation of people with refugee status (PWRS). The review focused on the role of proximal socio-structural barriers on work participation by PWRS while foregrounding related distal, intermediate, proximal, and meta-systemic influences. For the systematic search of the literature, we focused on databases that addressed work, well-being, and social policy in refugee populations, including, Medline, CINAHL, PsycInfo, Web of Science, Scopus, and Sociological Abstracts. Of the studies reviewed, 16 of 39 met the inclusion criteria and were retained for the final analysis. We performed a narrative synthesis of the evidence on barriers to work participation by PWRS, interlinking clusters of barriers potent to their effects on work participation. Findings from the narrative synthesis suggest that proximal factors, those at point of entry to the labor market, influence work participation more directly than distal or intermediate factors. Distal and intermediate factors achieve their effects on work participation by PWRS primarily through meta-systemic interlinkages, including host-country documentation and refugee administration provisions.

A critical regionalist approach to housing design in Vietnam : socio-environmental organisation of living spaces in pre- and post-reform houses

Vietnam has a unique culture which is revealed in the way that people have built and designed their traditional housing. Vietnamese dwellings reflect occupants’ activities in their everyday lives, while adapting to tropical climatic conditions impacted by seasoning monsoons. It is said that these characteristics of Vietnamese dwellings have remained unchanged until the economic reform in 1986, when Vietnam experienced an accelerated development based on the market-oriented economy. New housing types, including modern shop-houses, detached houses, and apartments, have been designed in many places, especially satisfying dwellers’ new lifestyles in Vietnamese cities. The contemporary housing, which has been mostly designed by architects, has reflected rules of spatial organisation so that occupants’ social activities are carried out. However, contemporary housing spaces seem unsustainable in relation to socio-cultural values because they has been influenced by globalism that advocates the use of homogeneous spatial patterns, modern technologies, materials and construction methods. This study investigates the rules of spaces in Vietnamese houses that were built before and after the reform to define the socio-cultural implications in Vietnamese housing design. Firstly, it describes occupants’ views of their current dwellings in terms of indoor comfort conditions and social activities in spaces. Then, it examines the use of spaces in pre-reform Vietnamese housing through occupants’ activities and material applications. Finally, it discusses the organisation of spaces in both pre- and post-reform housing to understand how Vietnamese housing has been designed for occupants to live, act, work, and conduct traditional activities. Understanding spatial organisation is a way to identify characteristics of the lived spaces of the occupants created from the conceived space, which is designed by designers. The characteristics of the housing spaces will inform the designers the way to design future Vietnamese housing in response to cultural contexts. The study applied an abductive approach for the investigation of housing spaces. It used a conceptual framework in relation to Henri Lefebvre’s (1991) theory to understand space as the main factor constituting the language of design, and the principles of semiotics to examine spatial structure in housing as a language used in the everyday life. The study involved a door-knocking survey to 350 households in four regional cities of Vietnam for interpretation of occupancy conditions and levels of occupants’ comfort. A statistical analysis was applied to interpret the survey data. The study also required a process of data selection and collection of fourteen cases of housing in three main climatic regions of the country for analysing spatial organisation and housing characteristics. The study found that there has been a shift in the relationship of spaces from the pre- to post-reform Vietnamese housing. It also indentified that the space for guest welcoming and family activity has been the central space of the Vietnamese housing. Based on the relationships of the central space with the others, theoretical models were proposed for three types of contemporary Vietnamese housing. The models will be significant in adapting to Vietnamese conditions to achieve socioenvironmental characteristics for housing design because it was developed from the occupants’ requirements for their social activities. Another contribution of the study is the use of methodological concepts to understand the language of living spaces. Further work will be needed to test future Vietnamese housing designs from the applications of the models.

Fostering wellbeing of immigrants and refugees? Evaluating the outcomes of work integration social enterprise

Work integration social enterprises (WISE) seek to create employment and pathways to employment for those highly disadvantaged in the labour market. This chapter examines the effects of WISE on the wellbeing of immigrants and refugees experiencing multiple barriers to economic and social participation. Drawing on an evaluation of a programme that supports seven such enterprises in the Australian state of Victoria, the effects of involvement for individual participants and their communities are examined. The study finds that this social enterprise model affords unique local opportunities for economic and social participation for groups experiencing significant barriers to meaningful employment. These opportunities have a positive impact on individual and community-level wellbeing. However, the financial costs of the model are high relative to other employment programmes, which is consistent with international findings on intermediate labour market programmes. The productivity costs of WISE are also disproportionately high compared to private sector competitors in some industries. This raises considerable dilemmas for social enterprise operators seeking to produce social value and achieve business sustainability while bearing high productivity costs to fulfil their mission. Further, the evaluation illuminates an ongoing need to address the systemic and structural drivers of health and labour market inequalities that characterize socio-economic participation for immigrants and refugees.

Low vitamin B12 levels among newly-arrived refugees from Bhutan, Iran and Afghanistan : a multicentre Australian study

Background: Vitamin B12 deficiency is prevalent in many countries of origin of refugees. Using a threshold of 5% above which a prevalence of low Vitamin B12 is indicative of a population health problem, we hypothesised that Vitamin B12 deficiency exceeds this threshold among newly-arrived refugees resettling in Australia, and is higher among women due to their increased risk of food insecurity. This paper reports Vitamin B12 levels in a large cohort of newly arrived refugees in five Australian states and territories. Methods: In a cross-sectional descriptive study, we collected Vitamin B12, folate and haematological indices on all refugees(n = 916; response rate 94% of eligible population) who had been in Australia for less than one year, and attended one of the collaborating health services between July 2010 and July 2011. Results: 16.5% of participants had Vitamin B12 deficiency (,150 pmol/L). One-third of participants from Iran and Bhutan, and one-quarter of participants from Afghanistan had Vitamin B12 deficiency. Contrary to our hypothesis, low Vitamin B12 levels were more prevalent in males than females. A higher prevalence of low Vitamin B12 was also reported in older age groups in some countries. The sensitivity of macrocytosis in detecting Vitamin B12 deficiency was only 4.6%. Conclusion: Vitamin B12 deficiency is an important population health issue in newly-arrived refugees from many countries. All newly-arrived refugees should be tested for Vitamin B12 deficiency. Ongoing research should investigate causes,treatment, and ways to mitigate food insecurity, and the contribution of such measures to enhancing the health of the refugee communities.

Well-being of refugees from Burma: a salutogenic perspective

A salutogenic approach explored themes of strength and well-being in life stories of Burmese refugees (N = 18) in Australia. Previous refugee studies have tended to focus on negative responses to traumatic events (e.g. posttraumatic stress disorder, depression). To widen the scope of refugee related research the focus of the current study was informed by a salutogenic perspective, exploring sources of strength that may facilitate well-being. Semi-structured narrative interviews explored: the participant's life before fleeing Burma, the journey of exile, and post-migration in Australia. Eight women and 10 men (Mage = 39 years) were interviewed and transcriptions analysis of narratives was conducted using Interpretative Phenomenological Analysis (IPA), with major themes being explicated. Super-ordinate themes pertaining to strength during times of hardship were identified and explicated as: support from interpersonal relationships, the pivotal role of values, a sense of future and agency, and reliance on spiritual or religious beliefs. Results indicate the existence of sources of strength that may contribute to human responses in times of hardship. Recognition and reflection of strengths may be incorporated into therapeutic and resettlement approaches for people from refugee backgrounds.

Protection of Refugees and Displaced Persons in the Asia Pacific Region

The chapters in this book explore the impact of recent shifts in global and regional power and the subsequent development and enforcement of international refugee protection standards in the Asia Pacific region. Drawing on their expertise across a number of jurisdictions, the contributors assess the challenges confronting the implementation of international law in the region, as well as new opportunities for extending protection norms into national and regional dialogues. The case studies span key jurisdictions across the region and include a comparative analysis with China, Indonesia, Thailand, Myanmar, Malaysia, Bangladesh and Australia. This topical and important book raises critical questions for the Asia Pacific region and sheds light on the challenges confronting the protection of refugees and displaced persons in this area. Interdisciplinary in its approach, it will be of interest to academics, researchers, students and policy-makers concerned with the rights and protection of refugees.