In reference to the article published in June 2009 issue of HRJ by Adnan A Khan and colleagues titled “Large sharing networks and unusual injection practices explain the rapid rise in HIV among IDUs in Sargodha, Pakistan” we would like to bring to your attention and readers certain issues that we believe are pertinent to qualitative research particularly focus group discussions. The authors state that 150 IDUs were interviewed in four focus group discussion (FGD) and 30 out reach workers in another focus group discussion. This is a major methodological flaw of conducting an FGD. While this process provides rich information due to flexibilities in the method however, having about 38 persons in one FGD does not seem right. Methodological issues of FGD were discussed in a review in 2004 by McLafferty (1). The article states that experiences of conducting focus group interviews demonstrated that smaller groups were more manageable. In a different study in Nigeria FGD (2) were conducted to improve condom negotiating skills among women and the number of participants in each FGD was 8-10. The authors also mention in the method that IDUs moved freely during the discussion, which also seem like a distraction and more importantly whether the discussion was tape recorded or how the notes were taken is not stated at all. It is also not clear how the consent was obtained and whether the study was ethically reviewed.
In the results it is mentioned that used syringes cost about the same as new one is incomprehensible simply because it is not possible that an old syringe can cost like a new one.
We conducted integrated behavioral and biological surveillance along with geographic mapping during 2006-07 (3). We recruited four hundred IDUs from the population of 2,450 by deploying probability sampling. Our findings were contrary to author’s observation to which he acknowledges at the later part of discussion. Our field experience indicates that in the medium size town of Sargodha IDUs are widely found except in cantonment area. They have satellite shooting sites which are away from main dwelling, situated where heroin is easily available and law enforcement is rarely operational. These lively sites among fields are managed by drug peddlers and are venues of their sale. Any sample from these sites does not reflect the overall situation within the city. Our findings indicate that mean age of IDUs is 31.6 years and they inject on average for the last four years contrary to author’s two years. Almost half of them are married and the same number is illiterate as well. Mean number of per day injection is 2.8 + 1.6, and 39.4% of sampled required services of professional injector (PI). PI are generally hired because of in-accessibility of veins and advanced thrombophlebitis leading to hardening of vessel. We found that the high frequency of daily injections i.e., >4 times to be 38.2% in sample of four hundred. However, this is exceptionally high compared to other four cities sampled within the province.
Our data indicate that only 2.5% were injecting 6-7 injections daily. Though high cost of these daily injections (Rs 60*30 days= Rs 1,800/- or USD 22.5) is less affordable for the average income of Rs 2,800 i.e., USD 35. Present findings are less suggestive of actual high rise of HIV as we don’t have base line HIV prevalence data. However, it may explain the local situation in small community where main injection behavior of “double pump” can be blamed even though it is performed during normal injection to ensure that needle is in the vein. Undoubtedly, reuse of “scale” even in the chance of ABO incompatibility, exposed to dry and hot conditions can lead to rapid spread of HIV among its beneficiaries. Despite this explanation in our opinion there are multiple causes of rapid rise. A more detailed operational research with proper methodology shall provide more insight to the milieu of Sargodha. We also enforce that main thrust of service delivery in such setting remain consistent supply of syringes, increased quota for frequent injectors, rapid collection of used syringes and strong BCC messages for IDUs.
References 1.McLafferty I. Focus group interviews as a data collecting strategy. J Adv Nurs. 2004 Oct;48(2):187-94 2.Mccallister S. Focus group discussions -- a tool for learning and organizing. Hesperian Found News. 1998 Summer:4-5. 3.Punjab AIDS Control Program & Canada-Pakistan HIV/AIDS Surveillance Project (HASP), HIV Second Generation Surveillance in Pakistan, Provincial Report Round II, 2006-07, p 36.
Harm Reduction Journal
Validating findings of qualitative and quantitative research
7 July 2009
Naeem Hasan Saleem, Arshad Altaf
In reference to the article published in June 2009 issue of HRJ by Adnan A Khan and colleagues titled “Large sharing networks and unusual injection practices explain the rapid rise in HIV among IDUs in Sargodha, Pakistan” we would like to bring to your attention and readers certain issues that we believe are pertinent to qualitative research particularly focus group discussions. The authors state that 150 IDUs were interviewed in four focus group discussion (FGD) and 30 out reach workers in another focus group discussion. This is a major methodological flaw of conducting an FGD. While this process provides rich information due to flexibilities in the method however, having about 38 persons in one FGD does not seem right. Methodological issues of FGD were discussed in a review in 2004 by McLafferty (1). The article states that experiences of conducting focus group interviews demonstrated that smaller groups were more manageable. In a different study in Nigeria FGD (2) were conducted to improve condom negotiating skills among women and the number of participants in each FGD was 8-10. The authors also mention in the method that IDUs moved freely during the discussion, which also seem like a distraction and more importantly whether the discussion was tape recorded or how the notes were taken is not stated at all. It is also not clear how the consent was obtained and whether the study was ethically reviewed.
In the results it is mentioned that used syringes cost about the same as new one is incomprehensible simply because it is not possible that an old syringe can cost like a new one.
We conducted integrated behavioral and biological surveillance along with geographic mapping during 2006-07 (3). We recruited four hundred IDUs from the population of 2,450 by deploying probability sampling. Our findings were contrary to author’s observation to which he acknowledges at the later part of discussion. Our field experience indicates that in the medium size town of Sargodha IDUs are widely found except in cantonment area. They have satellite shooting sites which are away from main dwelling, situated where heroin is easily available and law enforcement is rarely operational. These lively sites among fields are managed by drug peddlers and are venues of their sale. Any sample from these sites does not reflect the overall situation within the city. Our findings indicate that mean age of IDUs is 31.6 years and they inject on average for the last four years contrary to author’s two years. Almost half of them are married and the same number is illiterate as well. Mean number of per day injection is 2.8 + 1.6, and 39.4% of sampled required services of professional injector (PI). PI are generally hired because of in-accessibility of veins and advanced thrombophlebitis leading to hardening of vessel. We found that the high frequency of daily injections i.e., >4 times to be 38.2% in sample of four hundred. However, this is exceptionally high compared to other four cities sampled within the province.
Our data indicate that only 2.5% were injecting 6-7 injections daily. Though high cost of these daily injections (Rs 60*30 days= Rs 1,800/- or USD 22.5) is less affordable for the average income of Rs 2,800 i.e., USD 35. Present findings are less suggestive of actual high rise of HIV as we don’t have base line HIV prevalence data. However, it may explain the local situation in small community where main injection behavior of “double pump” can be blamed even though it is performed during normal injection to ensure that needle is in the vein. Undoubtedly, reuse of “scale” even in the chance of ABO incompatibility, exposed to dry and hot conditions can lead to rapid spread of HIV among its beneficiaries. Despite this explanation in our opinion there are multiple causes of rapid rise. A more detailed operational research with proper methodology shall provide more insight to the milieu of Sargodha. We also enforce that main thrust of service delivery in such setting remain consistent supply of syringes, increased quota for frequent injectors, rapid collection of used syringes and strong BCC messages for IDUs.
References
1.McLafferty I. Focus group interviews as a data collecting strategy. J Adv Nurs. 2004 Oct;48(2):187-94
2.Mccallister S. Focus group discussions -- a tool for learning and organizing. Hesperian Found News. 1998 Summer:4-5.
3.Punjab AIDS Control Program & Canada-Pakistan HIV/AIDS Surveillance Project (HASP), HIV Second Generation Surveillance in Pakistan, Provincial Report Round II, 2006-07, p 36.
Competing interests
None