I. LITERATURE SEARCH AND FORMULATION OF RESEARCH QUESTIONS
Preliminary research was done to gain familiarity with the subject by reading the internal MSF literature on its work in Kenya. The mission reports highlighted the poorer access to testing and care among Homa Bay’s male population. According to the observations in Homa Bay, these men were considered a population reluctant to seek preventive or curative HIV care. Lastly, the mortality rate for HIV-positive patients at the Homa Bay Hospital was higher for males, particularly for those diagnosed prior to admission. Therefore, studying access to HIV care for the male population seemed interesting and important.
Based on our literature search, we formulated the following questions:
1) What are the representations of HIV among Homa Bay’s male population?
2) How do those representations impact the demand for care?
3) How are people informed about and tested for HIV, and how does this impact male representations and practices?
4) Is the care that is offered tailored appropriately to the men in Homa Bay?
Our literature search looked for studies focused on a variety of health situations – studies that looked at the factors that determine testing campaign participation (HIV-related campaigns, in particular) in a given population. Those studies also pointed us to previous research on the gender issue, and in particular on gender-related differences in access to HIV care.
The final phase of the preliminary theoretical work was done at the Médecins Sans Frontières headquarters in Paris. We consulted the MSF archives regarding its work in Kenya from the 1980s to the present in order to familiarize ourselves with the workings of the mission – in particular, in the context of HIV projects, testing strategies, changes in practices, and progress made.
The working hypotheses formulated as a result of the literature search were as follows:
1) The issues presented by HIV prevention and testing conflict with other issues, and are incorporated with varying degrees of difficulty into men’s lives.
2) The moment at which a man becomes aware of HIV may be a pivotal one, at which he adopts certain prevention behaviors and considers being tested. However, prevention and care-seeking behaviors may vary depending on the representations of HIV that new awareness calls forth.
3) Men’s lower utilization of care in Homa Bay County may be due to a mismatch between the representations of HIV that prevail among men and the care services offered by governmental and non-governmental organizations.
The resulting study objectives are as follows:
Primary objective of the study:
• To evaluate male representations of HIV and the impact of those representations on care seeking.
Secondary objectives of the study:
• To evaluate the practices of different medical institutions, and how they impact the male population and their representations of HIV.
• To evaluate whether the care services offered in Homa Bay County are in line with male representations and expectations with regard to HIV.
II. STUDY POPULATION
The study involved the male population of Homa Bay County, which is 95% Luo. One portion of the study population was recruited from the male inpatient unit at Homa Bay Hospital, which treats both HIV-positive and non-HIV-positive patients. The HIV-positive patients were not necessarily on antiretrovirals, and may or may not have been hospitalized for an HIV-related illness. At the same time, clinically stable patients being followed by Clinic B or outlying health centers (for prescription refills and clinical follow-up) were interviewed.
After that, we conducted semi-structured interviews with some of the men who had taken part in community-based testing, and thus HIV-negative or of unknown status prior to testing. HIV-negative men over age 18 years seen during a testing visit were offered the opportunity to participate in the study after their test.
Other men were included independent of testing campaigns, during chance meetings or meetings arranged by intermediaries. The selection criterion for that population was age over 18 years.
The interviews used to meet the secondary objectives were conducted mainly during testing campaigns. In some cases, MSF helped us connect with the government or community representatives responsible for organizing testing missions. We met with other individuals without MSF’s help, via meetings in the field or connections made outside of the study context. Once the person agreed to participate, we applied no other selection criteria beyond age over than 18 years.
III. SEMI-STRUCTURED INTERVIEWS
The men encountered during door-to-door testing were interviewed at their homes; the rest of the family was asked to leave. Those interviews were done after the HIV test, in order to tie into what had just been said. That also allowed us to observe how the testing sequences took place, the medical information that was given, and the similarities and differences in testing practices by the various members of the medical corps. By studying these testing practices we were able to discern the messages aimed at the men and the ones that appeared frequently or more rarely. And that helped elicit more precisely the experience of their test visits.
An experienced bilingual English-Luo interpreter translated the questions and answers for the interviews conducted in Luo. The interpreter was present throughout the study, and for all of the interviews. The interpreter was accustomed to doing translation work for interview-based studies. A male interpreter was preferred, to make the men more comfortable when talking about personal subjects.
The interviews were recorded by Dictaphone. They lasted one hour, on average. Various subjects were broached; interviewees were not forced to answer a set series of questions, but allowed to express themselves as freely as possible and then to go back to or emphasize subjects that they considered more relevant or important. The questions were open-ended. The interview might be more structured, depending on the person being questioned and the expansiveness of his responses, and in those cases the questions might be more detailed. At the end of the interview, the subjects were offered an opportunity to go through the interview again to go back to subjects they deemed important or inadequately explored. The point of offering to repeat the interviews was to make them more like a dialog than an interview, by creating a “relationship” between the researcher and the subject and enable access to other information, which would be truer to personal experience.
IV. PARTICIPANT OBSERVATION
In parallel with the interviews, we observed the workings of the MSF mission. Participant observation is an expression used by some anthropologists and is applicable in sociology, as well (65). Participant observation is an integral part of the field survey.
This active observation can result in the creation of recorded “corpus data,” which are included in the study results or become part of what Olivier de Sardan calls “impregnation” (65), which while not part of the listed, recognizable data in the final written work, enables the researcher to better understand the setting in which it evolved. I observed formal education and therapeutic education sequences, days dedicated to monitoring HIV-positive adolescents, and advising or monitoring sequences for adult HIV patients.
Most of the results of this study meet the primary objective and come from interviews with the male population. Yet the results and discussion in this study are not solely the fruit of formal interviews. An entire portion of the discussion came from various meetings, informal interviews, and observation of different situations and therapeutic and medical sequences. Unexpected reflections raised new questions that then had to be confirmed or refuted by interview.
The knowledge obtained from the survey was supplemented by consulting local writings, Luo literature, in particular – admittedly sparse, but rich in information on Luo culture and practices, as described several decades ago. Luo writings were studied and discussed with the translator and with others after that, in particular with regard to the current persistence of certain practices or representations.
That part of the work, done on in the field, was useful in several ways; first, it enhanced the semi-structured interviews aimed at meeting the study’s primary objective. That then allowed us to compare several sources of data and reflection in an attempt to meet the secondary objective, that is, to know how well the care being offered met the expectations of the male population.