Nossal Institute for Global Health - Research Publications
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ItemKAP surveys and malaria control in Vietnam: findings and cautions about community research(SEAMEO Tropmed, 2005-05)The malaria disease burden is increasing in many countries despite the existence of effective preventative strategies and antimalarial drugs. An understanding of community perspectives and practices is one of the essential components of a successful malaria control program. This paper reports on a KAP (Knowledge, Attitudes and Practices) survey among the Raglai ethnic minority population in Ninh Thuan Province, Vietnam, which in 2003 had one of the country's highest confirmed rates of malaria. We found high levels of correct knowledge about malaria's transmission and symptoms, and self-reports of adequate bed net usage and appropriate health-seeking behavior. While the survey generated useful findings, an initial, qualitative investigation (eg, observation and focus group discussions) to explore the large numbers of potential influences on behavior and exposure risk would have provided a more robust underpinning for the design of survey questions. This would have strengthened its validity and generated additional information. The adoption of rigorous, multi-disciplinary research methods offers the best chance of contributing to the development of successful malaria control programs and effective policies.
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ItemHarm reduction and law enforcement in Vietnam: influences on street policing(BIOMED CENTRAL LTD, 2012-07-09)BACKGROUND AND RATIONALE: The HIV epidemic in Vietnam has from its start been concentrated among injecting drug users. Vietnam instituted the 2006 HIV/AIDS Law which includes comprehensive harm reduction measures, but these are unevenly accepted and inadequately implemented. Ward police are a major determinant of risk for IDUs, required to participate in drug control practices (especially meeting quotas for detention centres) which impede support for harm reduction. We studied influences on ward level police regarding harm reduction in Hanoi to learn how to better target education and structural change. METHODS: After document review, we interviewed informants from government, NGOs, INGOs, multilateral agencies, and police, using semi-structured guides. Topics covered included perceptions of harm reduction and the police role in drug law enforcement, and harm reduction training and advocacy among police. RESULTS: Police perceive conflicting responsibilities, but overwhelmingly see their responsibility as enforcing drug laws, identifying and knowing drug users, and selecting those for compulsory detention. Harm reduction training was very patchy, ward police not being seen as important to it; and understanding of harm reduction was limited, tending to reflect drug control priorities. Justification for methadone was as much crime prevention as HIV prevention.Competing pressures on ward police create much anxiety, with performance measures based around drug control; recourse to detention resolves competing pressures more safely. There is much recognition of the importance of discretion, and much use of it to maintain good social order. Policy dissemination approaches within the law enforcement sector were inconsistent, with little communication about harm reduction programs or approaches, and an unfounded assumption that training at senior levels would naturally reach to the street. DISCUSSION: Ward police have not been systematically included in harm reduction advocacy or training strategies to support or operationalise legalised harm reduction interventions. The practices of street police challenge harm reduction policies, entirely understandably given the competing pressures on them. For harm reduction to be effective in Vietnam, it is essential that the ambiguities and contradictions between laws to control HIV and to control drugs be resolved for the street-level police.
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ItemSmoking among Lao medical doctors: challenges and opportunities for tobacco control(BMJ PUBLISHING GROUP, 2011-03)BACKGROUND: Smoking is an increasing threat to health in low-income and middle-income countries and doctors are recognised as important role models in anti-smoking campaigns. OBJECTIVES: The study aimed to identify the smoking prevalence of medical doctors in Laos, their tobacco-related knowledge and attitudes, and their involvement in and capacity for tobacco prevention and control efforts. METHODS: This was a cross-sectional national survey by a researcher-administered, face-to-face questionnaire implemented at provincial health facilities throughout the central (including national capital), northern and southern regions of Laos in 2007. Both descriptive and inferential statistics were used. RESULTS: Of the 855 participants surveyed, 9.2% were current smokers and 18.4% were ex-smokers; smoking was least common in the central region (p<0.05) and far more prevalent in males (17.3% vs 0.4%; p<0.001). Smoking was concentrated among older doctors (p <0.001). Over 84% of current smokers wanted to quit, and 74.7% had made a recent serious attempt to do so. Doctors had excellent knowledge and positive attitudes to tobacco control, although smokers were relatively less knowledgeable and positive on some items. While 78% of doctors were engaged in cessation support, just 24% had been trained to do so, and a mere 8.8% considered themselves 'well prepared'. CONCLUSION: The willingness of doctors to take up their tobacco control role and the lower smoking rates among younger respondents offers an important window of opportunity to consolidate their knowledge, attitudes, skills and enthusiasm as cessation advocates and supports.
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ItemFostering disability-inclusive HIV/AIDS programs in northeast India: a participatory study(BMC, 2007-06-26)BACKGROUND: Manipur and Nagaland in northeast India are among the Indian states with the highest prevalence of HIV. Most prevention and care programs focus on identified "high risk" groups, but recent data suggest the epidemic is increasing among the general population, primarily through heterosexual sex. People with disability (PWD) in India are more likely than the general population to be illiterate, unemployed and impoverished, but little is known of their HIV risk. METHODS: This project aimed to enable HIV programs in Manipur and Nagaland to be more disability-inclusive. The objectives were to: explore HIV risk and risk perception in relation to PWD among HIV and disability programmers, and PWD themselves; identify HIV-related education and service needs and preferences of PWD; and utilise findings and stakeholder consultation to draft practical guidelines for inclusion of disability into HIV programming. Data were collected through a survey and several qualitative tools. RESULTS: The findings revealed that participants believe PWD in these states are potentially vulnerable to HIV transmission due to social exclusion and poverty, lack of knowledge, gender norms and obstacles to accessing HIV programs. Neither HIV nor disability organisations currently address the risks, needs and preferences of PWD. CONCLUSION: The Guidelines produced in the project and disseminated to stakeholders emphasise opportunities for taking action with minimal cost and resources, such as using the networks and expertise of both HIV and disability sectors, producing HIV material in a variety of formats, and promoting accessibility to mainstream HIV education and services. The human rights obligations and public health benefits of modifying national and state policies and programs to assist this highly disadvantaged population are also highlighted.
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ItemDocumenting a long-term development model in the slums of Delhi(BIOMED CENTRAL LTD, 2016-04-28)BACKGROUND: Achieving development outcomes requires the inclusion of marginalised populations that have the least opportunity to participate in and benefit from development. Slum dwellers often see little of the 'urban advantage', suffering more from infectious diseases, increasing food costs, poor access to education and health care, inadequate water and sanitation, and informal employment. A recent Cochrane Review of the impact of slum upgrading strategies found a dearth of unbiased studies, making it difficult to draw firm conclusions. The Review calls for greater use of process data, and qualitative alongside quantitative methods of evaluation. India is a lower middle income nation with large gender disparities and around 65 million slum inhabitants. The Asha Community Health and Development Society, a non-governmental organisation based in Delhi, has delivered a multi-sectoral program across 71 slums since 1988. This article reports on a mixed-method study to document measureable health and social impacts, along with Asha's ethos and processes. METHODS: Several observational visits were made to 12 Asha slums where informal discussions were had with staff and residents (n = 50). Asha data records were analysed for change over time (and differences with greater Delhi) in selected indicators (maternal-child health, education, child sex ratio) using descriptive statistics. 34 semi-structured individual/small group interviews and 14 focus group discussions were held with staff, residents, volunteers, elected officials, civil servants, bankers, diplomats, school principals, slumlords and loan recipients (n = 147). RESULTS: Key indicators of health and social equity improved over time and compared favourably with those for greater Delhi. The Asha model emphasises rights, responsibilities, equity and non-violence. It employs strategies characterised by long-term involvement, systematic protocols and monitoring, development of civil society (especially women's and children's groups) to advocate for rights under the law, and links with foreign volunteers and fund-raisers. Stakeholders agreed that changes in community norms and living conditions were at least partly attributable to the Asha model. CONCLUSIONS: While lacking a control group or complete baseline data, evidence suggested substantial improvements in slum conditions and social equity. The Asha model offers some lessons for slum (and broader) development.
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ItemSocial context, diversity and risk among women who inject drugs in Vietnam: descriptive findings from a cross-sectional survey(BMC, 2015-10-16)BACKGROUND: Women who inject drugs (WWID) are neglected globally in research and programming yet may be likelier than males to practise sexual and injecting risks and be infected with HIV and more stigmatised but seek fewer services. Little is known about characteristics, practices and nexus between drugs and sex work of WWID in Vietnam, where unsafe injecting has driven HIV transmission, and commercial sex and inconsistent condom use are prevalent. This was the first quantitative investigation of Vietnamese WWID recruited as injecting drug users. This article summarises descriptive findings. FINDINGS: A cross-sectional survey was conducted among WWID in Hanoi (n = 203) and Ho Chi Minh City (HCMC) (n = 200) recruited using respondent-driven sampling. Characteristics varied within and between sites. Twenty-two percent in Hanoi and 47.5 % in HCMC had never sold sex. Almost all commenced with smoking heroin, some as children. Most injected frequently, usually alone, although 8 % (Hanoi) and 18 % (HCMC) shared equipment in the previous month. Some had sex--and sold it--as children; most had multiple partners. Condom use was high with clients but very low with intimate partners, often injecting drug users. HIV knowledge was uneven, and large minorities were not tested recently (or ever) for HIV. Nearly all perceived intense gender-related stigma, especially for drug use. CONCLUSION: This ground-breaking study challenges assumptions about characteristics and risks based on anecdotal evidence and studies among men. Most WWID were vulnerable to sexual HIV transmission from intimate partners. Interventions should incorporate broader sociocultural context to protect this highly stigmatised population.
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ItemPathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community(BMC, 2009-03-23)BACKGROUND: There is increasing interest in underlying socio-cultural, economic, environmental and health-system influences on the persistence of malaria. Vietnam is a Mekong regional 'success story' after dramatic declines in malaria incidence following introduction of a national control program providing free bed-nets, diagnosis and treatment. Malaria has largely retreated to pockets near international borders in central Vietnam, where it remains a burden particularly among impoverished ethnic minorities. In these areas commune and village health workers are lynchpins of the program. This study in the central province of Quang Tri aimed to contribute to more effective malaria control in Vietnam by documenting the non-biological pathways to malaria persistence in two districts. METHODS: Multiple and mixed (qualitative and quantitative) methods were used. The formative stage comprised community meetings, observation of bed-net use, and focus group discussions and semi-structured interviews with health managers, providers and community. Formative results were used to guide development of tools for the assessment stage, which included a provider quiz, structured surveys with 160 community members and 16 village health workers, and quality check of microscopy facilities and health records at district and commune levels. Descriptive statistics and chi-square analysis were used for quantitative data. RESULTS: The study's key findings were the inadequacy of bed-nets (only 45% of households were fully covered) and sub-optimal diagnosis and treatment at local levels. Bed-net insufficiencies were exacerbated by customary sleeping patterns and population mobility. While care at district level seemed good, about a third of patients reportedly self-discharged early and many were lost to follow-up. Commune and village data suggested that approximately half of febrile patients were treated presumptively, and 10 village health workers did not carry artesunate to treat the potentially deadly and common P. falciparum malaria. Some staff lacked diagnostic skills, time for duties, and quality microscopy equipment. A few gaps were found in community knowledge and reported behaviours. CONCLUSION: Malaria control cannot be achieved through community education alone in this region. Whilst appropriate awareness-raising is needed, it is most urgent to address weaknesses at systems level, including bed-net distribution, health provider staffing and skills, as well as equipment and supplies.
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ItemThe impact of human immunodeficiency virus (HIV) service scale-up on mechanisms of accountability in Zambian primary health centres: a case-based health systems analysis(BMC, 2015-02-18)BACKGROUND: Questions about the impact of large donor-funded HIV interventions on low- and middle-income countries' health systems have been the subject of a number of expert commentaries, but comparatively few empirical research studies. Aimed at addressing a particular evidence gap vis-à-vis the influence of HIV service scale-up on micro-level health systems, this article examines the impact of HIV scale-up on mechanisms of accountability in Zambian primary health facilities. METHODS: Guided by the Mechanisms of Effect framework and Brinkerhoff's work on accountability, we conducted an in-depth multi-case study to examine how HIV services influenced mechanisms of administrative and social accountability in four Zambian primary health centres. Sites were selected for established (over 3 yrs) antiretroviral therapy (ART) services and urban, peri-urban and rural characteristics. Case data included provider interviews (60); patient interviews (180); direct observation of facility operations (2 wks/centre) and key informant interviews (14). RESULTS: Resource-intensive investment in HIV services contributed to some early gains in administrative answerability within the four ART departments, helping to establish the material capabilities necessary to deliver and monitor service delivery. Simultaneous investment in external supervision and professional development helped to promote transparency around individual and team performance and also strengthened positive work norms in the ART departments. In the wider health centres, however, mechanisms of administrative accountability remained weak, hindered by poor data collection and under capacitated leadership. Substantive gains in social accountability were also elusive as HIV scale-up did little to address deeply rooted information and power asymmetries in the wider facilities. CONCLUSIONS: Short terms gains in primary-level service accountability may arise from investment in health system hardware. However, sustained improvements in service quality and responsiveness arising from genuine improvements in social and administrative accountability require greater understanding of, and investment in changing, the power relations, work norms, leadership and disciplinary mechanisms that shape these micro-level health systems.
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ItemWorld Vision: Gender Equality Study(World Vision Australia, 2014)