#PHTwitJC 5: Paper summary & discussion points (qualitative study)

Ghimire et alThe paper selected for Public Health Twitter Journal Club discussion on 30th October  2011 is Ghimire et al (2011) ‘Reasons for non-use of condoms and self-efficacy among female sex workers: a qualitative study in Nepal’, BMC Women’s Health 11: 42.

This follows our poll on a shortlist of recent  qualitative research papers with relevance for HIV/AIDS.

Live twitter chat will begin at 8.00pm UK time (GMT) on Sunday 30th October. Remember to use the #PHTwitJC hashtag to follow and contribute to the discussion. For further tips on how to join in a Twitter chat, see the ‘About’ page above.

The issue

HIV/AIDS is recognised as  a major global public health problem, that has emerged in the past thirty years.  Main transmission routes for the virus (HIV) are sexual  intercourse, injecting drug use,  and mother-to-child transmission during pregnancy, birth or breastfeeding.

It has had a particularly devastating effect in low-middle income countries.  In 2009 an estimated 33.3 million people worldwide were living with HIV, of whom around 2/3 were in sub-Saharan Africa (UNAIDS 2010).

According to UNAIDS and WHO estimates, approximately 4.9 million people in the Asia & Pacific region (which includes Nepal) were living with HIV in 2009. This figure remained stable since the last estimate in 2005. Incidence is estimated at just over 300,000 new cases per year in the region, a drop of 20% over the previous ten years.  Access to treatment (in the form of anti-retroviral therapy, ART) has increased over the last five years but varies between countries. Overall in the region around one third of people eligible for ART are receiving it (UNAIDS 2011).

Reasons for HIV’s hitting poorest countries hardest include:

  • accessibility of general healthcare services and HIV treatment;
  • poverty & ‘survival strategies’ that may include high-risk behaviours;
  • education / access to preventive measures;
  • discrimination and stigma.

Structural factors such as political and cultural norms are  recognised potential barriers to reducing infection rates and increasing access to treatment:

Almost all countries in the [Asia & Pacific] region have laws, policies and practices that hamper the AIDS response and compromise the human rights of key affected communities.

(UNAIDS 2011)

Intergovernmental health efforts have given HIV/AIDS a high priority; however individual regimes’ commitment to tackling the issue vary. The ‘Getting to Zero’ campaign agreed at a UN High Level Meeting on AIDS in summer 2011 set a target of, ‘Zero new HIV infections, Zero discrimination, and Zero AIDS-related deaths.’ Interim targets to be met by 2015 include halving sexual transmissions of HIV.

Sex work and HIV

People who buy and sell sex are acknowledged as one of the most vulnerable groups in HIV/AIDS terms.  Sex work presents a challenge to HIV/AIDS interventions because it is ‘continually evolving’, may not be formalised, and there is a lack of focus on clients rather than sex workers. UN statistics show that 75%  of female sex workers in Nepal said they had used a condom with their most recent client (UNAIDS 2011). The paper we are going to discuss uses qualitative methods to dig beneath that statistic, suggesting that although female sex workers know that this is the ‘correct’ answer, in practice there are many reasons condoms may not be used during sexual transactions.


This country snapshot is taken from the 2011 UNAIDS report on the region (full reference at end of post):

The paper

Fifteen female sex workers (FSWs) in the Kathmandu Valley, Nepal, gave in-depth interviews lasting 2-5 hours, exploring isues of safe sex and risk management. The interview schedule was prepared in English and translated into Nepali.  These data appear to have been collected as part of a larger study: interviewees were recruited after having completed a larger-scale survey interview of 425 FSWs; the abstract also refers to ‘extended field observation’, although this is not explicitly discussed in the paper.

Findings: the women revealed frequent non-use of condoms with both regular (non-paying) sexual partners such as husbands, and with paying clients. Most of the women were ‘aware that proper condom use was an effective preventive measure for HIV’ (p.14).  Their explanations for non-use of condoms are presented in various ways: their lack of power (‘low self-efficacy’ ) in the relationship (e.g. their economic need);  fear of being identified as a sex worker (by intimate partners or law enforcement authorities); assumption that regular or ‘higher class’ clients were more respectable and therefore presented a lower risk; intimidation and violence from police (where carrying condoms may be automatically construed as an indicator of illegal activity).

Conclusions: ‘Economic empowerment of women and other structural interventions may provide a more sustainable means of STI and HIV prevention by strengthening the ability of communities to help individuals to reduce these risks and vulnerabilities’. The authors sugggest that a combination of behavioural & empowerment interventions for FSWs; along with improvements in health service provision and policy/legislative changes, will be most effective for this group.

Discussion points:

  1. Were the aims of the study clear?
  2. Were the sampling and data collection methods clear and appropriate?
  3. What ethical issues are raised by the study; are they discussed appropriately?
  4. Are the findings justifiable using the data collection/ analysis methods and selections of data (quotes from the women) presented?
  5. What do the findings tell us about female sex work and condom use in Nepal? Are they generalisable to other settings?
  6. What implications do the findings have for public health practice & policy?

These questions are broadly based around the ‘CASP’ appraisal tool for qualitative studies (PHRU 2006).



UNAIDS (2010) Global report: UNAIDS report on the global AIDS epidemic 2010.  UNAIDS, 2010.

UNAIDS (2011) HIV in Asia and the Pacific: Getting to Zero. Available online

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