April 11, 2011
Women and HIV Perception in Coimbatore, India
A Field Study Proposal
Statement of Intent
The primary purpose of this field study is to experience cultural immersion. I have never been to this area of the world and it has always interested me, particularly because of the many health issues that occur in India. For example, India has one of the highest HIV infection rates in the entire world. In order to decrease the HIV infection rate it is important to have an effective education program that teaches about the dangers of HIV and how it can be prevented. Therefore, it is important to have a basic understanding of the culture in which you are working and what they view as important otherwise the education programs that are implemented will not be effective. As a result, I would like to have an experience of researching a health issue while also taking into consideration the cultural implications of that culture and how those implications affect the education program. I think that this can only be done through cultural immersion. Through being able to live in and view the culture I hope to be able to begin to better understand the Eastern Indian value system. I also hope to be able to grow personally from being immersed. I am a firm believer that there are many ways to view life and I am interested in learning how people in India view life. I want to learn about topics such as what is important to them, how is the family run, how they find peace in their lives, what are their religious beliefs, etc. This experience will not only help me learn how to incorporate cultural understanding into public health education but it will also help me gain more knowledge of another culture.
I intend to work through an organization called Shanti Ashram and interview women who are being taught HIV prevention to see what their beliefs are on HIV, how it is spread, and how women in India view HIV. In addition, I plan on researching what methods Shanti Ashram is using in order to teach these women about HIV prevention in a culturally sensitive manner. In public health it is expected to be able to teach the masses how to change their lifestyle habits while being culturally sensitive. This generally is the biggest obstacle when trying to help someone change their behavior; therefore, gaining experience in this area will be beneficial to my future career. Being able to learn about the different ways of life and what is important to the people in southern India will help me gain a greater knowledge of the world and how I can better my life and the environment in which I am living.
The Human Immunodeficiency Virus (HIV) is a virus that attacks and destroys the human immune system. The only medication that is available is antiretroviral therapy, which is a series of expensive medications that must be taken for the rest of the infected person’s life. As a result, the most effective method for improving HIV is preventing it. Thus, prevention method programs are vital to the success of improving lives throughout the world. HIV is one of the most devastating diseases today, it affects millions of lives. In India it is estimated that that 5.2 million people are infected with HIV or one in eight of worldwide cases (Chandrasekaran, 2006, p. 508). In southern India there are high levels of HIV infection rate, in fact the first case of HIV was in southern India in the region of Tamil Nadu (Chandrasekaran, 2006, p. 509). In addition, women now contribute to half of all HIV infections worldwide and are therefore becoming the focal point for prevention programs (Chatterjee, 2006, p. 81).
As previously stated, the complication with HIV prevention is that research is showing that those that are at-risk are women that are in a monogamous relationship. In a recent study done in southern India, of the women that were infected with HIV, 81% were housewives (Chatterjee, 2006, p. 81). According to this study, married women have a risk perception that is low (they do not feel that they are at high-risk); however, in reality their risk is linked to the behavior of their husbands, which may increase their actual risk. In India, many religious beliefs, customs, and traditions have put women in exploitable positions. Due to low rates of education and economic independence women are generally dependent on the men in their lives (Sharma, 2005, p. 375). This dependence crosses over into what they do with their bodies in addition to their sexual practices. It has been suggested that married women have little ability to discuss using protection with their partners because of the patriarchal society in which they live (Gangakhedkar, 1997, p. 2091). This causes problems when trying to teach prevention methods to women because they are not in charge of their sexual practices. Indian women are doing everything in their power to have a safe lifestyle; however, they still become infected through their husbands who are not in a faithful relationship. So the question remains of how to help women understand the dangers of HIV transmission and how to protect themselves. Although prevention programs are important, they also must be adapted to the culture of those who are in need of the prevention. HIV is a common problem throughout the world and although the methods of prevention are generally the same, the methods of teaching those prevention techniques vary with each region.
In Coimbatore there is an organization known as Shanti Ashram that focuses on HIV prevention in the city as well as the surrounding areas. This organization is based off the understanding that religion plays an important role in the lives of the individual; as a result, part of the HIV prevention program involves working with local religious leaders to increase the awareness of HIV transmission. In addition to working with this organization I plan on finding other organizations and clinics to observe so that I will be able to view the different ways of teaching HIV prevention.
A common difficulty when addressing HIV is the stigma that is attached to this disease that makes it difficult to discuss. Most people do not think that it is appropriate to talk about HIV infection and believe false infection ideas. It is apparent that developing an effective prevention program is difficult under such circumstances and as a result I am interested in researching what prevention methods are being taught and how they are effective.
BYU Field Study has a history of sending students to Coimbatore, India. Coimbatore is the second largest city in the region of Tamil Nadu and it has a population of about 930,000 people. I plan to volunteer with Shanti Ashram, which is an organization that focuses on the education of the residents of southern India. Although it is based in Coimbatore, the actual organization goes to the rural areas around Coimbatore to implement its intervention programs. The program that I am interested in volunteering with is specifically HIV prevention. In order to promote HIV prevention, Shanti Ashram has organized seminars, co-produced discussion papers and facilitated workshops on HIV/AIDS, particularly on the role of Faith Based Organizations.
India has suffered from HIV since 1986, when the first case of HIV was found in Tamil Nadu. Since India has such a high prevalence of HIV, Shanti Ashram specifically works with ways to prevent HIV transmission. Therefore this is the perfect opportunity for me to study this subject matter in India.
For this project I will enter the community through the local organization, Shanti Ashram. I am making contact with this organization through the Field Studies’ office. Since many students have volunteered for Shanti Ashram in the past I do not foresee any difficulties in using this organization as a way to enter the community. During this study I will be doing semi-formal interviews with 15-20 women between the ages 18-35 who live within the region. Each interview will last roughly between 45-90 minutes. The participants will be chosen by their association with primarily Shanti Ashram. Each woman who is interviewed will be read the consent form and verbal consent will be asked. Interviews will be conducted with a female translator and notes will be taken by hand. Interview notes will be organized according to date and time and each woman will be given a pseudonym. The content of the findings will be discussed in my final research paper. Topics discussed in the interview will include the woman’s history: what type of education she has had, is she married or single, what are her daily activities, etc. This will help me gain a better understanding of the background of each woman and her lifestyle (e.g. if she has had the opportunity to have a formal education or not, if she is married, etc.). Any participant will be able to withdraw at any time during the interview if they feel uneasy or feel the need to stop.
After an idea of the lifestyle of the woman has been gained, questions will then be asked about the participant’s basic knowledge of health. For example, what their definition of health is, how to stay healthy, if they view health as an important subject, etc. Then the woman will be asked questions regarding HIV: what is HIV, how is it contracted, how does the subject view HIV, does the woman feel that HIV is an important issue, what are some health issues that the woman feels is important. Questions will also be asked regarding HIV transmission between mother and child: how is HIV transmitted, can it be prevented, etc. Finally, questions will be asked regarding how the subject got her information and how long ago this information was These data will help me understand if she learned about HIV from the organization, school, or if it is common knowledge. For a list of sample questions, please see appendix C.
In addition to holding semi-structured interviews I will observe the program provided by Shanti Ashram and view the prevention methods they teach, how they teach it, and their reasoning behind choosing this prevention program. This will be done by participant observation as a volunteer at the organization and speaking with the leaders of Shanti Ashram. I will continue the participant observation throughout the research process in India.
At the end of the interviewing process and participant observation I will review the notes taken and find the common trends and answers to the questions. If I feel that more information is need to draw conclusions on common responses I will request another interview that will last between 45-90 minutes.
Ethics and Approval
Since I will be working with sensitive information of the informants, I will explain the importance of confidentiality to my translator. In addition, before every interview I will request verbal consent from every woman and I will explain that all information will be kept confidential and that she may leave the interview at any time if she feels uncomfortable or no longer wishes to continue. I plan on keeping all written notes under lock and key while I am in India and I will be the only one allowed to view the raw data taken. I will give each woman a code name so that her real name will not be recorded. While writing my final paper I will change the names in order to maintain the privacy of those with whom I am working.
The risks associated with this research project are minimal. Since subjects may be HIV positive they could potentially be caused discomfort by speaking about their knowledge on the way the illness is contracted; however, the HIV status will not be asked. Also, HIV has a stigma that causes others to not want to discuss it; this could cause difficulty in trying to find people who are willing to discuss the topic of HIV. In order to minimize the risks I will inform all participants that they will be able to leave the study at any time if they feel uncomfortable or do not want to continue further. Also, I will minimize the risks by working through an established organization and holding the interviews at this organization.
The data that will be collected will provide more insight into how Eastern Indians view HIV transmission and prevention and how current programs are working within the culture to help spread knowledge about this disease. This will start to give more understanding on different beliefs about HIV in a different culture. There will be no direct benefits to participants in this study.
In order to maintain reciprocity with my host family I will aid in the daily activities of the home. For example, I will help carry the water back to the house; I will help in the kitchen and go to get food when needed. I will also occasionally buy some food to help out with family groceries and abide by the cultural norms of the area. In order to maintain reciprocity with Shanti Ashram I will volunteer with their organization and give my services to help out as much as I am able. I will also pay the translators who help me with the interviews. However, their method of payment will be decided according to the cultural norms.
Post Field Application
After returning from the field I plan to present my findings at the Inquiry Conference and also publish them in the Inquiry Journal. I plan to work with my mentor after my return in addition to working diligently to present my findings in an effective manner so that it will be adequate to share at the conference.
Eventually I will attend graduate school and study public health with an emphasis in global health. My long-term goal is to work with women throughout the world and develop programs to educate women on how to avoid health problems for themselves and their children. This field study will help me gain my first experience in global health. I have previously had international experiences and I have also previously had experience with public health research and prevention; however, this will be my first experience being involved with international public health. This field study will also be my first experience with mentored research, which will be a very useful skill while working in public health because much of public health involves researching health disparities and understanding the target audience so you are better equipped to help them and improve their level quality and quantity of life. My experience in India will be an important stepping stone for my future goals in public health.
Faculty Mentor and Coursework
My mentor, Dr. Eugene Cole is a full-time professor at Brigham Young University who received his MSPH and PhD at UNC with an emphasis in Global Health Promotion. He currently teaches infectious disease and refugee health in the Health Science Department. He has had research opportunities in South Africa and Southeast Asia working on health promotion. I took Infectious Disease course with Dr. Cole in the summer of 2010. During this course he shared a lot of his experiences with global health and shared his passion for promoting health and teaching prevention against infectious diseases. This is the main reason why I chose Dr. Cole to be my mentor. From experience I know he has extensive knowledge not only about infectious disease and research, but he also is very passionate about his work. I have learned that it is more effective to work with people who enjoy what they do and feel that it is important. As a result of Dr. Cole’s attitude and willingness help I have already been able to improve my research project.
As a Public Health major I have taken many classes that qualify me for this project. I have studied in depth infectious disease, program planning, international health, and women’s health. I am almost done with my major and as a result I have rigorously studied how to promote health education. In addition, I have interned for Intermountain Healthcare and have worked on several health promotion programs trying to educate the community about the health disparities of Utah County. In 2007 I took an extensive course through the Red Cross in which I became certified to teach about HIV to high risk populations. At this course we learned about prevention methods, how to talk to people who are at risk to get HIV, and how to get tested for HIV. As a result of my education I have adequate knowledge about HIV and the prevention techniques that are traditionally taught.
Although I feel that I am qualified for this project, I do have limitations that I acknowledge will make this field study more difficult. My limited knowledge of Tamil will make the interview and day to day process more difficult; however, the use of a translator will mitigate this limitation. Also, HIV is a taboo subject, making it difficult to discuss. In order to mitigate this problem I will be interviewing women who are associated with the HIV prevention program with Shanti Ashram, therefore they will be more accustomed to speaking about HIV. I also have limited interviewing skills; however, this will improve with time and practice.
My coursework will include Health 451, IAS 220, IAS 399R, and IAS 380R (see attached course contracts). Health 451 is health mentored research which will help me in my undergraduate research and how to be more effective. IAS 380R will help me to be able to be more fully immersed in the culture. Cultural proofs are a good way to experience the area that I am in and record my thoughts and ideas. This will help me enrich my experience during the field study. IAS 399R is an internship course where I will be able to read and study more about India, HIV and to record my experiences from working with Shanti Ashram. IAS 220 is required to finish the credit for the Field Study. Overall my selected courses are going to help me have a better cultural and academic experience in India. Through these classes I hope to be able to prepare for my future in global public health and research.
$1.00 USD = 44 INR
Visa: $80 (including visa application fee and mail services)
Rent-$105 (or $35/mo)
Food-$150 (or $50/mo)
June 6-July 3
Arrive in Coimbatore and get to know the area/people. Pay attention to customs and traditions. Volunteer and find first interviewees for July. Pay special attention with participant observation daily.
July 4-July 10
Interview 2 women. Continue with volunteer responsibility and participant observation.
July 1-July 17
Interview 3women. Continue with volunteer responsibility and participant observation.
Interview 2 women. Look for more women to interview in August. Continue with volunteer responsibilities/participant observation.
Interview 2 women. Continue with volunteer responsibilities/participant observation. Mid-term evaluation: review interviews and find ways to improve.
August 1-August 7
Interview 2 women. Continue with volunteer responsibilities/participant observation. Look for more women to interview.
August 8-August 14
Interview 2 women. Continue with volunteer responsibilities.
Interview 2 women. Continue with volunteer responsibilities/participant observation. Continue to find women to interview.
August 22-August 28
Interview 2 women. Finish finding women to interview. Review all interviews and schedule any secondary interviews (if necessary).
August 29-Sept. 4
Interview 2 women. Finish volunteer responsibilities and say goodbye to acquaintances.
Sept. 5-Sept. 11
Return home and review notes.
Sept. 12-Oct. 31
Write first draft of final paper. Submit to Dr. Cole for review.
Nov. 1-Nov. 31
Write second draft of paper and submit for review
Dec. 1-Dec. 15
Make final draft of final paper.
Submit final draft.
*Throughout my time spent in the field I will recap daily my findings and review ways to improve. A mid-term evaluation will be done at the end of July to see if my questions are providing the necessary data and also I will determine if another interview with the women previously interviewed is desired (e.g. if I find that there is a common answer between the women and I want to ask further questions). In addition, although I have the goal to interview about 2 women a week I understand that this may change once I get to the field and see the conditions of the area/quality of my interviews. As a result, the number of women interviewed a week may change according to the circumstances.
ReferencesBasanti, M. (2004). An exploration of socioeconomic, spiritual, and family support among HIV-positive women in India. Journal of the Association of Nurses in AIDS care, 15(3).
Brahme, R. (2006). Correlates and trend of HIV prevalence among female sex workers attending sexually transmitted disease clinics in Pune, India. JAIDS journal of Acquired Immune Deficiency Syndromes, 41(1).
Chandrasekaran, P. (2006). Containing HIV/AIDS in India: the unfinished agenda. The Lancet: Infectious Diseases, 6(8).
Chatterjee, N. (2006). Perceptions of risk and behavior change for prevention of HIV among married women in Mumbai, India. Journal of Health Population and Nutrition, 24(1).
Gangakhedkar, R. (1997). Spread of HIV infection in married monogamous women in India. JAMA, 278(23).
Gupta, J. (2009). HIV vulnerabilities of sex-trafficked Indian women and girls. International Journal of Gynecology and Obstetrics, (107)2.
Mencher. J. (1974). The caste system upside down or the not-so-mysterious east. Current Anthropology (15)4. Retrieved from: http://www.jstor.org.erl.lib.byu.edu/openurl?volume=15&date=1974&spage=469&issn=00113204&issue=4
Mokgatle-Nthabu, M. (2008). Safe sex practice among HIV positive women on antiretroviral therapy: a HIV prevention challenge for poor resourced settings. International journal of Infectious Diseases, (12).
Sharma, BR. (2005). Social etiology of violence against women in India. The Social Science Journal. (43)3.
Smita. J. (2005). Comparative acceptability study of the reality female condom and the version 4 of modified Reddy female condom in India. Contraception. (72)5.
Steward, W. (2008). HIV related stigma: adapting a theoretical framework for use in India. Social Science & Medicine, 67(8).
Vickerman, P. (2010). To what extent is the HIV epidemic in southern India driven by commercial sex? A modeling analysis. AIDS, 24(16).
Appendix C-Interview Questions
Interview Sample Questions
1) What is the highest level of education you have had?
2) Are you married? If so, how long have you been married?
3) Can you explain to me a time that you took care of a sick member of your family? What did you do?
4) Can you tell me about a time you changed an old habit so you could have a healthier lifestyle?
5) For you, what does the word healthy mean?
6) What illness are you most worried you/your family members will get? How many people do you know that have that illness?
7) What do you believe HIV is?
8) Can you tell me a story about what happened to someone who had HIV?
9) How do the people you know think HIV is transferred?
10) Is there a cure for HIV?
11) Can HIV be transferred from mother to child? How?
12) Can this be prevented? How?
13) Who are more at risk to get HIV; men or women? Why?
14) How can you be safe from HIV?
15) What is AIDS?
16) What is the relationship between HIV and AIDS?
17) Where can you go to learn more about HIV?
18) Where did you get your information from?
19) Why do you think more people are talking about HIV?
20) How many of your friends and family members know about HIV?
21) Can you tell me about a conversation you had or heard about HIV? What was said? Who said it?
22) What are important health concerns for southern India?
23) What do your female friends and family think is an important health concern in India?
Appendix D: Address and Title of Online Portfolio