Qualitative Health Research: Negotiating Life with HIV/AIDS

In this paper, I look at the use of qualitative methods in health geography. I focus on two projects using in-depth interviews with people with HIV/AIDS. Drawing from feminist work on qualitative methodologies and the production of knowledge, two questions are posed. First, what insights do interviews offer about people's daily experiences with HIV/AIDS? Second, given that interviews involve direct contact between interviewer and respondent, what are the implications of using this methodology? Projects reveal that living with HIV/AIDS involves a complex series of negotiations. These include negotiating one's own identity within medical discourse, dealing with health care professionals, and choosing how to use medication. The projects also indicate that qualitative research itself involves a process of negotiation. Researchers' preconceptions, interview settings and formats, and relationships established during research can effect research outcomes andresearch participants. I argue that a willingness to reflect critically on the use of qualitative methods is needed to safeguard against these unintended consequences.     

Healthier Geographies: Mediating the Gaps between the Needs of People Living with HIV and AIDS and Health Care in Chiang Mai,Thailand

In this article, I contribute to our understanding of the plurality of approaches that construct the geographies of health care through an examination of the distribution of health care services for people living with HIV/AIDS (PLWHA) in Chiang Mai Province, Thailand. In particular, I focus on the development of a network of support groups for PLWHA in order to examine the differences in the sociospatial organization of these groups, the practices of social actors participating in the groups' activities, and how these activities are mediated through place-based social relations. The first section of the article analyzes the spatial distribution of PLWHA support groups in relation to the distribution of AIDS cases over two time periods, 1994 and 1997. The second section goes below the surface of the spatial distribution, examining similarities and differences in PLWHA support groups through an analysis of survey data collected on thirty-five groups in 1997. The final section deepens this examination through an analysis of ethnographic data collected on the outreach efforts of one nongovernmental organization (NGO) and one PLWHA support group with which it worked. Each section offers opportunities for the extension of our understanding of the development of PLWHA support groups, their distribution in relation to the spread of AIDS cases, and their place-based meanings.     

Healthier Geographies: Mediating the Gaps between the Needs of People Living with HIV and AIDS and Health Care in Chiang Mai,Thailand

In this article, I contribute to our understanding of the plurality of approaches that construct the geographies of health care through an examination of the distribution of health care services for people living with HIV/AIDS (PLWHA) in Chiang Mai Province, Thailand. In particular, I focus on the development of a network of support groups for PLWHA in order to examine the differences in the sociospatial organization of these groups, the practices of social actors participating in the groups' activities, and how these activities are mediated through place‐based social relations. The first section of the article analyzes the spatial distribution of PLWHA support groups in relation to the distribution of AIDS cases over two time periods, 1994 and 1997. The second section goes below the surface of the spatial distribution, examining similarities and differences in PLWHA support groups through an analysis of survey data collected on thirty‐five groups in 1997. The final section deepens this examination through an analysis of ethnographic data collected on the outreach efforts of one nongovernmental organization (NGO) and one PLWHA support group with which it worked. Each section offers opportunities for the extension of our understanding of the development of PLWHA support groups, their distribution in relation to the spread of AIDS cases, and their place‐based meanings.     

Eliciting emotions in HIV/AIDS research: a diary-based approach

Little attention has been given to understanding the emotional well-being of people living with HIV/AIDS in developing countries, despite the fact that emotions may impact on people's sense of purpose and value, and ultimately their ability and resolve to hold livelihood and familial responsibilities together. Drawing upon research undertaken in the Caprivi Region of Namibia, this paper examines the use of solicited text and photo diaries in enabling insight into the emotional impacts of HIV/AIDS. The advantages and constraints of diary methods are examined, focusing on informant-directed research and the ethical considerations surrounding their use.     

Fluid Households,Complex Families: The Impacts of Children's Migration as a Response to HIV/AIDS in Southern Africa*

Abstract

The fluidity of southern African families is related to a long history of internal and external migration. Currently, HIV/AIDS is having a dramatic impact on extended family structures, with the migration of individual members employed as a coping strategy. Children's migration is one aspect of this that is often distinct from that undertaken by other household members. This article is based on qualitative research conducted in Lesotho and Malawi with young migrants and the households that receive them. It examines the processes of fragmentation and re-formation of households through the movements of children that are taking place in response to HIV/AIDS, and explores the impacts these processes have on young migrants and the households they join.     

Use of Space-Filling Curves in Generating a National Rural Sampling Frame for HIV/AIDS Research*

The classical geographic research problem of regionalization and resource allocation is most commonly tackled by means of location-allocation methods. This paper introduces the spatial-order method as an alternative for creating regions or clusters. The spatial-order method utilizes space-filling curves, also known as Peano curves, to determine the nearness or spatial order of areal units, such as counties. Given a capacity constraint, the areal units are grouped consecutively according to their spatial order values. We applied the method to create clusters of rural counties for a national sampling survey of HIV/AIDS patients in the United States. Using the criteria that each cluster had approximately 50 new AIDS cases in 1991–1993 and that contiguity of areal units was maximized, 226 clusters were created from the 1,853 rural counties or health districts. The rural clusters generated by this method have been adopted as the national rural sampling frame in the HIV Cost and Services Utilization Study (HCSUS) being undertaken by RAND. In addition to its simplicity and fast computational speed, the spatial-order method produces satisfactory results. With minor modifications, this method can be an efficient alternative to the location-allocation method for solving a wide variety of locational problems, such as routing, political districting, and facilities location and allocation. This paper also demonstrates how a classical geographic research methodology, with the enhancement of GIS, can contribute to the multidisciplinary study of a pressing societal problem in our nation.     

A Vulnerability Interpretation of the Geography of HIV/AIDS in Ghana, 1986–1995

Ten years after the human immuno-deficiency virus (HIV) was first reported in Ghana, it continues to spread throughout the country following patterns that are rare in other African countries. HIV is seen in twice as many females as males, more frequently in rural than urban regions, and regions with high rates of polygamy have significantly lower rates. The evidence presented in this paper shows that HIV diffusion patterns probably reflect the spatial distribution and social networks of vulnerable social groups. While information-based campaigns are still necessary in the fight against HIV/AIDS, they fail to enable or empower vulnerable people to protect themselves against infection.     

Economic vulnerability, beer and HIV/AIDS: The struggle to sustain farmer livelihoods and indigenous sorghum varieties in eastern Uganda

Drawing on a case study from eastern Uganda, this paper describes how social and environmental factors combine to affect the sustainability of both sorghum landraces and the farmers who depend on it for food and income security. It delineates how changing regional patterns of agricultural production and consumption, institutional neglect, economic hardship, natural resource degradation and a labour supply crisis precipitated by the HIV/AIDS pandemic, may be conspiring to place sorghum landraces at risk of extinction and, thus, undermine already precarious livelihoods. The paper therefore challenges the common assumption that marginalized rural women – by virtue of having diverse varieties and species under their care – can be expected to conserve that diversity.     

Fluid Households,Complex Families: The Impacts of Children's Migration as a Response to HIV/AIDS in Southern Africa*

The fluidity of southern African families is related to a long history of internal and external migration. Currently, HIV/AIDS is having a dramatic impact on extended family structures, with the migration of individual members employed as a coping strategy. Children's migration is one aspect of this that is often distinct from that undertaken by other household members. This article is based on qualitative research conducted in Lesotho and Malawi with young migrants and the households that receive them. It examines the processes of fragmentation and re‐formation of households through the movements of children that are taking place in response to HIV/AIDS, and explores the impacts these processes have on young migrants and the households they join.     

The gendered reconfiguration of low-income urban household space in response to AIDS: Perspectives from Botswana

The study focused on three main actors within low-income urban households in Gaborone, the capital of Botswana. These were primary care givers, persons living with AIDS (PLWA) and AIDS orphans. The survey investigated the extent to which the traditional family system was coping with provisioning for its PLWA and AIDS orphans, the level to which the main actors reorganize household space in response to evolving demands, to cater for PLWA and AIDS needs, and the degree to which such spatial reorganization resonates with the gendered utilization of household space. Although the methodology of this case study was mainly participatory, it also relied on documented literature from archival sources and the Internet for its conceptual, theoretical and statistical information. The results suggest that the traditional family system is failing to cope with care provision for the PLWA and AIDS-orphaned children and that adjustments to their increasing presence within the households influence the gendered reconfiguring of household space. The traditional gendered utilization of space is thus being constantly negotiated in response to the requirements of HIV patients and those of HIV/AIDS-orphaned children. The proliferating female HIV/AIDS patient care giving and orphan children guardianship appear to be threatening the central and pivotal position of the father figure within the patriarchal household setting.     

A Qualitative Study of the Professional Relationship between Family Physicians and Hospital Specialists

The professional relationships between family physicians (general practitioners or GPs) and specialist doctors are crucial in a referral-based national health service such as that in the United Kingdom. They may, for example, have a fundamental influence on what in the past have been assumed to be logical or proximity-based utilisation patterns of secondary and even tertiary hospital facilities if GPs refer to specialists with whom they have greater rapport. Until recently, research has identified a generally poor mutual understanding between the two key clinical branches of the National Health Service (NHS), and this research was conducted to determine the state of the current relationship. A range of qualitative methods was employed—including key informant interviews, focus groups, and in-depth interviews—with family doctors and specialists in the south and west region of the United Kingdom. The participants described a much better mutual relationship than that found in previous studies. Four major issues were identified relating to professional interaction. These included the reasons for choosing one of the two main branches of medicine in which to practice, the ways in which doctors interact over clinical issues, the effects of teaching and learning together on the relationship, and possible future models of professional interaction. In process terms, the theme of cooperation was more evident than that of conflict and there was minimal evidence of a struggle for power or status. If anything, the balance of influence within the profession seemed to be shifting in favour of the primary practitioners rather than the specialists. This research therefore indicates key variables for inclusion in future behavioural studies of the use of health services in physician referral-based systems. We illustrate the strengths and potential of qualitative methods in health care research and health care geography for investigating professional relationships which are likely to impact on patient care and service quality as well as being factors that might influence spatial patterns of patient behaviour.     

Negotiating Multiple Positionalities in the Interview Setting: Researching Across Gender and Generational Boundaries

This article explores the multiple positionalities that were negotiated during qualitative interviews conducted with older British men who are grandfathers, by a young female early career researcher. Gender and other methodological challenges negotiated by researchers of men and masculinities have been critiqued, but negotiations of age and generational differences in the field remain scant, despite recognition that age also structures socially constructed and spatially experienced identities. Including reflections on personal research experiences, the article outlines the need for explicit critical attention by geographers to the influence of the fluid intersectional identities of the researcher and researched on research experiences in the field and research outcomes.     

Social geography of risk: The role of time,place and antiretroviral therapy in conceptions about the sexual risk of HIV in Kahe,Kilimanjaro, Tanzania

The epidemiological pattern of HIV/AIDS in Africa and Tanzania is characterized by geographical variations in HIV prevalence. Despite the geographical variations, heterosexual contact remains the predominant mode of HIV transmission. The article examines the interrelationships of social, spatial and temporal issues in explaining the sexual risk of HIV/AIDS amongst youths in rural Tanzania. Drawing on discussions with young people, the authors employ a comparative approach to establish categories of social practices that explain HIV risk. HIV risk is largely influenced by social interaction as youths engage in routine day-to-day activities in different geographical locales. The availability of antiretroviral treatment ushered in new dynamics in locally available strategies to manage the risk of HIV infection. Gender relations appear to have an underlining influence in determining the timing and place of risk as well as ways of controlling risk. The study participants emphasized both social and biomedical interventions to manage and control sexual activity and risk. Youth-focused and community-wide interventions addressing HIV prevention, care and treatment need to recognize the fact that the HIV epidemic in Tanzania is increasingly becoming a rural phenomenon structured by a wide range of local, national and global processes.     

Urban encounters and sexual health among gay and bisexual immigrant men: perspectives from the settlement and aids service sectors

Gay men's health researchers in North America have recently attended to sexual and mental health issues affecting ethnic minority men, many of whom are also immigrants. Most of this work is grounded in epidemiological models that focus on relationships between individual HIV risk and sexual behaviors. Consequently, they the frame the sexual health of gay and bisexual immigrants as the product of cultural issues (for example, family and religious homophobia, lack of health education) or gay community issues (prevalence of drug use and casual sex) that lead to self‐devaluation, depression, and unprotected sex with multiple partners. Few studies, however, examine these phenomena through the lens of migration and resettlement. Using the narratives from twelve in‐depth interviews with settlement and AIDS Service Organization (ASO) workers in Toronto, Ottawa, and London, Ontario, Canada, this article examines four types of post‐migration urban encounters that influence sexual health: negotiations of resettlement‐related stress, encounters with the urban gay community, encounters with the online gay community, and encounters with sexual health promotion itself. The findings suggest that these encounters are important intervening events that mediate the relationship between the attributes of the immigrant and his sexual health behaviors and outcomes.     

Negotiating Knowledge Production: The Everyday Inclusions,Exclusions, and Contradictions of Participatory GIS Research*

Although participatory approaches to geographic information system (GIS) use have significantly altered the technological and social practices of GIS‐based research and decision making, they have received relatively little attention within discussions of participatory research. This paper examines how participation and representation are negotiated in participatory GIS research through everyday practices of knowledge production. Inclusion and exclusion in the production of knowledge in participatory GIS are mediated within several intersecting arenas of research practice simultaneously, often with contradictory implications, priorities, and outputs.     

AIDS mitigation through agriculture‐based interventions in rural contexts: Junior farmer field and life schools and future livelihoods in central Mozambique

This article summarizes findings from a research project on junior farmer field and life schools (JFFLS) as an agriculture‐based intervention to improve the livelihood prospects of children and orphans made vulnerable by HIV/AIDS in central Mozambique. In the sites investigated JFFLS have opened up concrete present and potential livelihood options in agriculture and beyond. More generally, the resource profile dynamics of participants are altered in ways that provide strong grounds to believe that the skills and knowledge they have gained will positively impact the trajectories of their future lives. In terms of HIV/AIDS mitigation, the findings recommend livelihood‐based interventions aimed at altering the vulnerability context of specific population groups.