Stigmatization as a social control mechanism for persons living with HIV and AIDS.

Stigmatization contributes to inequity by marginalizing persons living with HIV and AIDS (PHAs). In this study we examined the stigmatizing practices in health care settings from the perspectives of PHAs and health care providers (HCPs). A qualitative design, using a participatory action research approach, was used. Interviews and focus groups were completed with 16 aboriginal and 17 nonaboriginal individuals living with HIV (APHAs and PHAs) and 27 HCPs in Ottawa and Edmonton, Canada. We present findings to support the premise that stigmatization can be used as a social control mechanism with PHAs. Participants described both active and passive social control mechanisms: shunning and ostracizing, labeling, and disempowering health care practices. Forgiving behavior, balancing disclosure, practicing universal precautions, bending the rules, shifting services, and reducing labeling were strategies to manage, resist, and mitigate social control. The findings illustrate the urgent need for multilevel interventions to manage, resist, and mitigate stigma.

HIV testing and care in Canadian Aboriginal youth: a community based mixed methods study.

BACKGROUND: HIV infection is a serious concern in the Canadian Aboriginal population, particularly among youth; however, there is limited attention to this issue in research literature. The purpose of this national study was to explore HIV testing and care decisions of Canadian Aboriginal youth. METHODS: A community-based mixed-method design incorporating the Aboriginal research principles of Ownership, Control, Access and Possession (OCAP) was used. Data were collected through surveys (n = 413) and qualitative interviews (n = 28). Eleven community-based organizations including urban Aboriginal AIDS service organizations and health and friendship centres in seven provinces and one territory assisted with the recruitment of youth (15 to 30 years). RESULTS: Average age of survey participants was 21.5 years (median = 21.0 years) and qualitative interview participants was 24.4 years (median = 24.0). Fifty-one percent of the survey respondents (210 of 413 youth) and 25 of 28 interview participants had been tested for HIV. The most common reason to seek testing was having sex without a condom (43.6%) or pregnancy (35.4%) while common reasons for not testing were the perception of being low HIV risk (45.3%) or not having had sex with an infected person (34.5%). Among interviewees, a contributing reason for not testing was feeling invulnerable. Most surveyed youth tested in the community in which they lived (86.5%) and 34.1% visited a physician for the test. The majority of surveyed youth (60.0%) had tested once or twice in the previous 2 years, however, about one-quarter had tested more than twice. Among the 26 surveyed youth who reported that they were HIV-positive, 6 (23.1%) had AIDS at the time of diagnosis. Delays in care-seeking after diagnosis varied from a few months to seven years from time of test. CONCLUSION: It is encouraging that many youth who had tested for HIV did so based on a realistic self-assessment of HIV risk behaviours; however, for others, a feeling of invulnerability was a barrier to testing. For those who tested positive, there was often a delay in accessing health services.

The exodus of health professionals from sub-Saharan Africa: balancing human rights and societal needs in the twenty-first century.

Increased international migration of health professionals is weakening healthcare systems in low-income countries, particularly those in sub-Saharan Africa. The migration of nurses, physicians and other health professionals from countries in sub-Saharan Africa poses a major threat to the achievement of health equity in this region. As nurses form the backbone of healthcare systems in many of the affected countries, it is the accelerating migration of nurses that will be most critical over the next few years. In this paper we present a comprehensive analysis of the literature and argue that, from a human rights perspective, there are competing rights in the international migration of health professionals: the right to leave one's country to seek a better life; the right to health of populations in the source and destination countries; labour rights; the right to education; and the right to non-discrimination and equality. Creative policy approaches are required to balance these rights and to ensure that the individual rights of health professionals do not compromise the societal right to health.

Stigma associated with Ghanaian caregivers of AIDS patients.

This study explores the experiences of informal caregivers of AIDS patients in Accra, the capital city of Ghana. Fifteen interviews were completed in 2002 with 11 informal caregivers, including wives, mothers, boyfriends, daughters, sons and brothers of AIDS patients. Three major themes emerge in the analysis of the interviews with caregivers: stigma, caregiver burden, and caregiver commitment. In this article, the authors focus on the theme of stigma by documenting its presence and highlighting its impact on caregiving activities. Caregivers go to great effort to not only "hide" their patients but also their care giving activities, resulting in the social isolation of both patients and their caregivers. Many caregivers live in secrecy, not sharing their family member's diagnosis with extended family members. As a result, they receive limited support from the extended family. Stigma results in negative attitudes of neighbors, relatives, and health care workers toward caregivers and their patients.

Challenges and opportunities of international clinical practica.

International clinical practica are a strategy to integrate a global dimension in nursing curricula and achieve culturally sensitive nursing practice. In this paper, a review of the history and development of international practica for nursing students is presented, and research evaluating the effectiveness and impact of international experiences is analyzed. A description of experiences working with Canadian nursing students is used to highlight the challenges and opportunities inherent to international clinical practica. International student experiences involving clinical practica pose challenges that are additional to, and often more complex than, those faced in traditional international, course-based exchanges. The significant opportunities, however, continue to make international student practica a desirable and positive experience for Canadian nursing students.

Shrouded in secrecy: breaking the news of HIV infection to Ghanaian women.

The purpose of this research was to examine the experience of HIV-positive Ghanaian women and to identify factors that influenced their vulnerability to infection. The study was carried out in Ghana from January to May 1999 using participatory action research. In-depth interviews and focus groups with 31 HIV-positive women, 5 HIV-positive men, 8 nurses, 10 professionals, and 2 traditional healers were used to collect the data. The need for secrecy in "breaking the news" emerged as an important theme. Secrecy affected the women's access to treatment and to financial and emotional support from families. The secrecy surrounding breaking the news of HIV infection is one manifestation of AIDS stigma in Ghana. Encouraging disclosure within a trusting and supportive environment may be one strategy to diffuse AIDS stigma in Ghana. Educational interventions to eliminate AIDS stigma among health care professionals, including nurses, are required in Ghana.

Establishing methodological rigour in international qualitative nursing research: a case study from Ghana.

BACKGROUND: Attention to rigour, from the identification of the problem to the dissemination of the findings, is essential in all qualitative research. In this paper, research carried out in Ghana in 1999 is used to highlight methodological issues in relation to rigour in international qualitative nursing research. AIM: The purpose of this paper is to review the literature in relation to rigour in qualitative research, highlight the methodological decisions enhancing rigour during this research project, and describe the criteria used to assess rigour during the research process. DESIGN: A participatory action research design was used to explore the cultural, social, economic, and political factors that influenced Ghanaian women's vulnerability to HIV infection. Collaboration with participants and partnerships with key professionals were integral to the design of the study. FINDINGS: Participatory action research provided a flexible, socially, and culturally adaptable framework to guide this international research project. Prior to the initiation of international research it was essential to establish the relevance and feasibility of the proposed project. This international research project posed additional methodological challenges to the establishment of rigour. Patience, flexibility and sensitivity were required of the researcher to overcome these challenges. CONCLUSION: Collaboration with participants and with culture-specific 'experts' may be key to culturally competent scholarship, particularly in unfamiliar settings.

Ethical decision making in international nursing research.

Researchers in international settings must continually examine cross-cultural ethical issues to ensure that their work is ethically sound. In this article, the authors discuss the process of ethical decision making in international nursing research. They draw on research in Ghana during 1999 involving HIV seropositive women to document this process. Referring to this experience, they argue that international research involving human beings must meet two related but distinct ethical tests: It must meet international ethical standards for the protection of human participants but, at the same time, acknowledge the ethical standards related to the institutional setting and cultural environment in which the research takes place.

HIV risk environment for Ghanaian women: challenges to prevention.

Ghana is experiencing high rates of HIV transmission and women have been identified as a group with increased vulnerability to infection. Women's vulnerability may be influenced by factors such as gender, unequal power relationships and poverty. Research was undertaken in Ghana from January to May 1999 to examine the experiences of HIV sero-positive women. Thirty-one women were interviewed to explore the broad context of disease transmission and to identify factors that mediated women's ability to protect themselves from infection. The poverty experienced by many of the women during their childhood years, coupled with a societal belief that favored the education of males, restricted the participants' educational and vocational opportunities. With limited education and few vocational skills, many of the women took boyfriends to assist them with the purchase of food, clothing and shelter, as a strategy for survival. For most women, the use of condoms with sexual partners was restricted by the high value placed on fertility, the negative association of condoms with prostitution, and the women's limited ability to influence decision-making in this area. The women's narratives provide a compelling description of the context of HIV transmission in Ghana. Strategies to expand and intensify the response to HIV prevention are presented and critiqued.