Should we tell the truth? Why families in Japan chose to tell their loved ones they were victims of iatrogenic HIV infection

HIV in Japan: Epidemiologic puzzles and ethnographic explanations

Japan is widely perceived to have a low level of HIV occurrence; however, its HIV epidemics also have been the subject of considerable misunderstanding globally. I used a ground truthing conceptual framework to meet two aims: first, to determine how accurately official surveillance data represented Japan's two largest epidemics (urban Kansai and Tokyo) as understood and experienced on the ground; and second, to identify explanations for why the HIV epidemics were unfolding as officially reported. I used primarily ethnographic methods while drawing upon epidemiology, and compared government surveillance data to observations at community and institutional sites (459 pages of field notes; 175 persons observed), qualitative interviews with stakeholders in local HIV epidemics (n = 32), and document research (n = 116). This revealed seven epidemiologic puzzles involving officially reported trends and conspicuously missing information. Ethnographically grounded explanations are presented for each. These included factors driving the epidemics, which ranged from waning government and public attention to HIV, to gaps in sex education and disruptive leadership changes in public institutions approximately every two years. Factors constraining the epidemics also contributed to explanations. These ranged from subsidized medical treatment for most people living with HIV, to strong partnerships between government and a well-developed, non-governmental sector of HIV interventionists, and protective norms and built environments in the sex industry. Local and regional HIV epidemics were experienced and understood as worse than government reports indicated, and ground-level data often contradicted official knowledge. Results thus call into question epidemiologic trends, including recent stabilization of the national epidemic, and suggest the need for revisions to the surveillance system and strategies that address factors driving and constraining the epidemics. Based upon its utility in the current study, ground truthing has value as a conceptual framework for research and shows promise for future theoretical development.

HIV's Syndemic Links With Mental Health, Substance Use, and Violence in an Environment of Stigma and Disparities in Japan

A syndemics orientation has become a valuable lens through which to understand the complex system dynamics of HIV, HIV's links to other social and health problems, and the design of effective, comprehensive interventions. Using data from a broader ethnographic study of HIV epidemics in the Kansai Region and Tokyo Metropolitan Area of Japan, I found that HIV was synergistically linked with poor mental health, substance use, and violence, suggesting the existence of at least three syndemics. These occurred in an environment of stigma and social and health disparities, particularly for men who have sex with men, transgender persons, immigrants, and people living with HIV. Integrated interventions, led by Japan's HIV nongovernmental organizations and supported by the government, should more aggressively target stigma, which underlies most of the syndemic connections. Quantitative research should build upon the ethnographically derived associations shown here and test whether there are additive syndemic effects.

Indigenous people's experiences at the end of life

OBJECTIVE

The primary purpose of this metasynthesis study was to explore the end-of-life experiences of Indigenous peoples by synthesizing the findings of qualitative research.

METHOD

Sandelowski and Barroso's methodology for synthesizing qualitative research was used and included (a) a comprehensive search, (b) appraising reports of qualitative studies, (c) classification of studies, and (d) synthesis of the findings. Research team members guided this process. This team was multidisciplinary and included Indigenous and non-Indigenous researchers from Canada, Australia, New Zealand, and the United States. Following a comprehensive search, 2255 studies were reviewed and assessed against five inclusion criteria: (a) studies on the experiences of Indigenous populations (all genders, 18 + years of age) at the end of life, (b) studies published in English from any country, (c) studies using qualitative and mixed-methods designs, and (d) studies published between 1993 and 2013.

RESULTS

Some 18 studies met the inclusion criteria, and their findings were synthesized. "Preparing the spirit" for transition to the next life was the overarching theme. "Preparing the spirit" occurred within the context of "where we come from." Processes involved in "preparing the spirit" were healing, connecting, and protecting; through these processes, "what I want at the end of life" was realized. Although not the focus of the metasynthesis, a significant finding was that the studies reviewed identified very clear barriers within healthcare systems and current healthcare provider practices to "preparing the spirit."

SIGNIFICANCE OF RESULTS

The findings provide a beginning understanding of the end-of-life experiences of Indigenous peoples and a foundation for future research. More interpretive qualitative research is critical if palliative care services, the healthcare system, and healthcare providers are to reduce current barriers to "preparing the spirit" for the journey at the end of life.

Hiding the plot: parents' moral dilemmas and strategies when helping their overweight children lose weight

In this study we investigated the moral dilemmas and strategies of a group of Danish parents who were trying to help their overweight children lose weight. Data were drawn from repeated semistructured interviews carried out over a period of 2 years with 12 families with overweight children. Using a narrative approach, we show the moral dilemmas parents found themselves in when trying to further the two seemingly incompatible goals of helping their children lose weight and simultaneously strengthening their self-worth. When the children were young, the parents tried to hide the fact that they needed to lose weight to protect them from feeling stigmatized. As the children grew older, the parents became more forthright about weight loss so the children would take on more responsibility. We suggest that for parents, weight loss is experienced as a risky undertaking because they perceive their children's self-worth as being in jeopardy during the process.

"What happens on the van, stays on the van": the (re)structuring of privacy and disclosure scripts on an Appalachian mobile health clinic

Over the past two decades, mobile health clinics have emerged to address the health needs of underserved populations. Mobile clinics offer curbside care in the primary settings of people's lives: churches, parking lots, grocery stores, and community centers. Drawing on 18 months of ethnographic fieldwork, I explore how physical and symbolic space helps shape the (re)writing of traditional health care scripts of provider-patient confidentiality and medical disclosure in a mobile clinic serving residents of 21 counties in southeastern Ohio. This analysis centered on how clinic staff members blurred the symbolic and physical space of privacy, merged personal and professional discourses, and triaged multiple patient disclosures in the face of social and spatial constraints.

Lost the feel for the game: meanings of onset and diagnosis of AIDS dementia for significant others

The onset and diagnosis of AIDS dementia marks a new dimension to living with HIV, an aspect few imagine or are equipped for. As a result of the profound changes that AIDS dementia makes to the ways the person with HIV acts, the life of significant others is similarly altered. Drawing on the metaphor of "the game" from Bourdieu's work on habitus, I explore how the onset and subsequent diagnosis of AIDS dementia comes to signify for significant others a moment in which life is permanently altered, whereby they no longer have the feel for the game. With AIDS dementia, life ("the game") is altered. Significant others feel that AIDS dementia is not a normal or acceptable AIDS illness: fears are contested, secrets managed and disclosed, and relations strained. This change in play further marginalizes significant others, and increases their sense of alterity from others living with and affected by HIV alone, because dementia is not the socially acceptable way of being ill with HIV.