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Culture, Risk and HIV: the Case of Black African Migrants and Refugees in Christchurch, New Zealand

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Culture, Risk and HIV: the Case of Black African Migrants and Refugees in Christchurch, New Zealand Culture, Risk and HIV: The Case of Black African Migrants and Refugees in Christchurch, New Zealand Gerida Joseph Birukila A thesis submitted for the degree of Doctor of Philosophy University of Otago, Dunedin, New Zealand July 2012 Abstract Black African migrants and refugees are disproportionately affected by heterosexually acquired HIV in New Zealand. Despite this, there are no data on their HIV related sexual attitudes, beliefs and behaviours. This sequential mixed methods study aimed to address this gap. The study had four phases: community consultation, social mapping, a survey, and focus group discussions. Ten community researchers were nominated during consultation and received training in research methods. The community researchers used social mapping techniques to identify social venues and events (such as churches, mosques, soccer games, drums of Africa, Miss Africa Christchurch, baby showers, hair salons, universities, colleges and formal and informal community organisations) from which to recruit participants for the survey phase. The questionnaire from the Mayisha I study in the UK was adapted for use in this study. The survey used a self-administered questionnaire on HIV-related sexual behaviours, attitudes and practices. A sub-sample of survey participants was purposively selected and invited to attend the focus group discussions to explore the issues identified in the survey findings in more depth. In total, 250 participants completed the survey questionnaire and five focus groups were conducted. Participants came from 13 different countries in Africa (Tanzania, Kenya, Ghana, Nigeria, Somalia, Ethiopia, Eritrea, Sudan, South Africa, Zimbabwe, Zambia, Malawi and Botswana). Risk factors identified in this study included low condom use, low HIV risk perception, having more than one sexual partner (including concurrently) and previous sexually transmitted disease (STD) diagnosis. Focus group discussions identified that cultural beliefs and practices played a key role in influencing risk perception, attitudes towards condom use, the practice of multiple concurrent partnerships (MCP), and gender violence. Some of these beliefs were not compatible with the biomedical understandings and approaches that commonly underpin HIV prevention programmes. There is a need therefore to develop HIV prevention programmes that are culturally informed and appropriate to the needs of black Africans in New Zealand. I Acknowledgments My PhD journey has been a humbling one. There were two main events on that journey that I will always remember. First, the death of my original supervisor, the late Oliver Davidson, whom I had known and worked with for four years. This was a big loss for me and it took me time to get back on track. Second, the two major earthquakes that hit Christchurch in September 2010 and February 2011 which meant the loss of our Department’s building and working space. The earthquakes have affected every aspect of our lives, then and since. To the African community in Christchurch, especially community leaders, community researchers and religious leaders, I thank you all for allowing me to conduct this study in your community and for sharing your stories. I thank the University of Otago, the Dunbar Research Scholarship, and the Departments of Public Health and General Practice, Christchurch and Preventive and Social Medicine in Dunedin for funding my studies. Thanks also to Professor Charles Tustin for his support in navigating University processes. I would like to thank my first team of supervisors, the late Associate Professor Oliver Davidson and Professor Ann Richardson, who left the University in 2009. I am very grateful to my supervisors Dr Cheryl Brunton, Dr Lee Thompson and Associate Professor Nigel Dickson. Cheryl, thank you for taking charge and directing my studies in the right direction during the hard times, especially after the death of my original supervisor. I am also grateful to you for helping me secure funding that enabled me to complete my thesis and for having an open door policy. Lee, thank you for pushing me to go deeper in the world of qualitative analysis. Your expertise in this area is exceptional and I am forever grateful for the skills you imparted to me. Thank you too for being there for me always. Nigel, thank you for agreeing to supervise me and providing timely feedback. I was privileged to work with you in this area of HIV and AIDS and benefited from your expertise, experience and knowledge. Thank you all for being both patient and kind. II I am very grateful to the Department of Public Health and General Practice, especially the Head of Department, Professor Les Toop, for his support. Thank you also to Associate Professor Elisabeth Wells for providing me with expert advice in quantitative data analysis. I would also like to thank other staff in the Department, especially Yvonne O’Brien, Trish Clements, Jill Winter and Dr Gillian Abel for their friendship and support. Thank you to Verna Braiden for proof reading and Dr Lynley Cook for her help formatting my thesis. I would like also to thank Roz Martin of the Department of Psychological Medicine for her support during the early days of my research. My thanks also to Ruth Helms and the IT team at UOC (Anna, Robert, Tim and Andrew) for all their help. To my husband Thomas and my children Kwame, Kwadwo and Abena, thank you for your sacrifice, understanding and for believing in me. To my beloved grandmother Amelia (deceased), who was never given an opportunity to go to school, because ‘she was a girl’ and as a result she instilled in us the hunger for knowledge and education. Lastly, I thank God Almighty for in Him we live, move and have our being. III Dedication This thesis is dedicated to my first supervisor, the late Associate Professor Oliver Davidson (July 1959 – July 2009). Without him this study would not have been possible. You will never be forgotten Oliver and your work among Africans will live on. IV Abbreviations ABC Abstain, Be faithful, Condom use AEG AIDS Epidemiology Group AIDS Acquired Immune Deficiency Syndrome ARV Antiretroviral BBC British Broadcasting Cooperation BC Before Christ CALD Culturally and Linguistically Diverse CD4 Cluster of Differentiation 4 (a glycoprotein found on the surface of immune cells) CDC Centres for Disease Control CI Confidence Interval CNN Cable News Network DAH Deutsche AIDS-Hilfe DHS Demographic Health Survey ECDPC European Centre for Disease Prevention and Control EU European Union FGM Female Genital Mutilation FHI Family Health International GPA Global Programme on AIDS HAART Highly Active Antiretroviral Therapy HBM Health Belief Model HIV Human Immune-deficient Virus HPA Health Protection Agency HSV Herpes Simplex Virus IAS International AIDS Society IOM International Organisation for Migration KFF Keiser Foundation Fund MAA Migrants Against AIDS MC Male Circumcision MCPs Multiple Concurrent Partnerships MH Mantel Haenszel MSM Men who have Sex with Men NAP National AIDS Programme NZ New Zealand NZAF New Zealand AIDS Foundation NZIS New Zealand Immigration Services PHAC Public Health Agency Canada PMTCT Prevention of Mother To Child Transmission RNA Ribonucleic Acid SPSS Statistical Package for the Social Sciences SSRC Social Science Research Council STD Sexually Transmitted Disease STI Sexually Transmitted Infection TACAIDS Tanzanian Commission for AIDS TRA Theory of Reasoned Action TZ Tanzania V UAE United Arab Emirates UK United Kingdom UN United Nations UNAIDS Joint United Nations Programme on HIV/AIDS UNESCO United Nations Education Scientific and Cultural Organisation UNHCR United Nations High Commissioner for Refugees UNICEF United Nations Children Education Fund USA United States of America USAID United States AID agency VCT Voluntary Counselling and Testing WHO World Health Organization VI Table of Contents Abstract .......................................................................................................................... I Acknowledgments......................................................................................................... II Dedication.................................................................................................................... IV Abbreviations ................................................................................................................ V Table of Contents .......................................................................................................... 1 List of Figures ............................................................................................................... 5 List of Tables ................................................................................................................. 6 Preface ........................................................................................................................... 8 Chapter 1 Introduction ............................................................................................... 13 1.1 Introduction ................................................................................................................. 13 1.2 The Mayisha Studies: UK and NZ ............................................................................. 15 1.3 Aims and Objectives ................................................................................................... 16 1.4 Structure of the Thesis ................................................................................................ 16 Chapter 2 Black Africans, New Zealand
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