Targeted ethnography as a critical step to inform cultural adaptations of HIV prevention interventions for adults with severe mental illness

Abstract

As in other countries worldwide, adults with severe mental illness (SMI) in Brazil are disproportionately infected with HIV relative to the general population. Brazilian psychiatric facilities lack tested HIV prevention interventions. To adapt existing interventions, developed only in the U.S., we conducted targeted ethnography with adults with SMI and staff from two psychiatric institutions in Brazil. We sought to characterize individual, institutional, and interpersonal factors that may affect HIV risk behavior in this population. We conducted 350 hours of ethnographic field observations in two mental health service settings in Rio de Janeiro, and 9 focus groups (n = 72) and 16 key-informant interviews with patients and staff in these settings. Data comprised field notes and audiotapes of all exchanges, which were transcribed, coded, and systematically analyzed. The ethnography characterized the institutional culture and identified: 1) patients' risk behaviors; 2) the institutional setting; 3) intervention content; and 4) intervention format and delivery strategies. Targeted ethnography also illuminated broader contextual issues for development and implementation of HIV prevention interventions for adults with SMI in Brazil, including an institutional culture that did not systematically address patients' sexual behavior, sexual health, or HIV sexual risk, yet strongly impacted the structure of patients' sexual networks. Further, ethnography identified the Brazilian concept of "social responsibility" as important to prevention work with psychiatric patients. Targeted ethnography with adults with SMI and institutional staff

Prevalence of HIV, syphilis, hepatitis B and C among adults with mental illness: a multicenter study in Brazil

“…The point prevalence of HIV, syphilis, hepatitis B and C were shown to be higher when comparing to other Brazilian studies with probability samples of non-psychiatric populations, although some estimates were within the 95% confidence limits. Severe mental health conditions with lower perception of risk and cognitive impairment could partially explain these findings 7,19,20 . Also, lower socioeconomic conditions, lack of social support and poor access to health care may add to the burden of other medical conditions, including STI, to psychiatric patients 7,20 .…”

Validation of the Mental Illness Sexual Stigma Questionnaire (MISS-Q) in a sample of Brazilian adults in psychiatric care

“…For example, in this Brazilian outpatient sample, nearly half of patients reported being married; by contrast, in studies examining sexual behavior in the context of HIV risk, the vast majority of sexually active participants were single 16 . Our own measures were informed by carefully conducted ethnographic and other developmental work 9,17,18 . Other aspects of patients' stigma experiences may impinge upon their sexual relationships and these are worth examining in future studies.…”

“…Psychiatric patients continue to be stigmatized 2,3 and experience detrimental effects and discrimination in multiple systems (e.g., education, housing, work-force, health, mental health, judicial) and in their social networks 3,4 . Evidence suggests that labeling someone with mental illness influences sexuality and sexual behaviors as a contributor either to social and sexual isolation 5,6 or to increased sexual risk behaviors [7][8][9] . Expectations of romantic and sexual rejection by the person labeled with mental illness can lead to reduced confidence, constricted social networks, depression, and low self-esteem 3,9-11 and may interfere with achieving full potential for recovery 12,13 .…”

“…Our investigation into mental illness sexual stigma originated with psychiatric outpatients in the U.S. 6,7 . It was explored through ethnographic and other developmental work in Brazil 9,17,18 , resulting in a questionnaire with good testretest reliability (k =.75) 17 , that has been used in a U.S. pilot study of adolescents with psychiatric disorders 19 . However, the factorial structure and validity of the instrument have not been determined.…”

Assessment of Risk Sexual Behaviors among Adults at Adigrat Town, Tigray, Ethiopia

“…Clinicians should also consider the communities they serve. If the practice's population has a high rate of STIs, all sexually active patients in no monogamous relationships may be considered to be at increased risk (17,18).The Communicable Disease Control reported that the highest prevalence rate of HIV diagnoses in 2008 was among persons aged 45 to 54 years. In 2011, the population with the highest percentage of people diagnosed with HIV was persons aged 55 years and older .…”