In total, 53 people took part in 6 FGDs (27 men and 26 women), and 12 (6 men and 6 women) in KIIs. FGDs ranged in size from 8–10 participants. The median age for FGD participants was 30 (range
19 to 56) whereas median age for KIIs was 35 (range
23 to 48). Sixty-eight per cent of FGD and 83% of KII participants were married (see Table ). Over 60% of all the study participants were from the Northwest region of Cameroon. The majority had received either primary (40%) or secondary (47%) level education. Only a few (1.5%) had never been to school at all.
Characteristics of plantation FGD and KII participants in Cameroon, August-October 2006
Plantation camps were described as bringing together a multitude of people from different ethnic, religious, tribal, and social backgrounds. Participants reported that English-speaking populations from the Northwest region and French-speaking ethnic groups from the Central, West and Extreme North regions of the country constituted the largest recognizable social groups. Newcomers were reported to be most obvious during holidays when camp members were visited by relatives or at production seasonal peaks when contractors were looking to recruit new hires. Camp residents were depicted as mostly unmarried or as unaccompanied married men who had left spouses behind to seek plantation work. Women without stable partners were referred to as “free”. A workforce comprised largely of men was seen as having an economic draw for women outside of the camps, in particular sex workers. A female key informant explained, “There are girls who have come in from Douala. They are prostitutes. They come to look for men…. and they go in for them for money. They move from place to place, they do not have a stable place neither do they have any stable man. They are not married. If you offer them any money, they would go in for sexual intercourse or sexual relationship…almost at the end of every month when they are paying workers. They know that when they come they would earn some money and they can even spend a week here and when they have emptied the pockets of their clients they would go back.”
Participants identified themselves as being relatively unstable and mobile. They described plantation work as tedious and attributed their itinerant lifestyle to dependency on a plantation payment system marked by low and irregular wages. Additionally, participants reported that workers regularly request cash advances against expected earnings from the company, thus pushing them into a cycle of debt. Participants also reported that most plantation work was physically demanding (harvesting, pruning, pesticide application, picking and transportation of palm cones, etc.), therefore making it male-centred and less attractive for women. They stated that women because of their potential for underperformance (i.e., inability to keep up with the physical demands) often encountered hiring discrimination given the company’s concerns about profit margins. Alternating periods of employment and unemployment as well as limited facilities and resources (e.g., housing, schools, and potable water, electricity, and health services) were also said to contribute to the regular movement of people in and out of the plantation community.
CRAs observed that work in the plantations began as early as six o’clock in the morning and ended around two o’clock in the afternoon. Men’s work involved cutting palm cones, pruning fronds, and applying fertilizers and pesticides, while women gathered felled cones and nuts and transferred them to vehicle stations for transportation to processing factories. At the end of their work shift, a number of plantation workers were seen engaging in supplementary income-generating activities. For men, this included raising goats, pigs, or chickens, and tapping palm wine for sale or for personal consumption, trading, distilling and/or selling of locally-made gin known as ha. Women generally sold vegetables they brought back from their family farms, and other cooked food items, or sold a locally fermented beer known in the plantations as sha. At any time of the day, women could be found decorticating peanuts or pumpkin seeds and processing food either for personal consumption or for marketing around the corridors of their home.
Camp houses were constructed primarily of cement or wood, and had a rectangular uniform design. Wooden houses were occupied by unskilled labourers while the concrete ones housed administrative and technical staff. CRAs also observed across the camps that in many instances, three-to-four families might share a house. In this case, each family occupied a bedroom and used the living room as communal space. A female key informant states, “When new faces [people] come they do not have houses to stay because the houses are not enough and if they have a relation they would crowd there and the relation would not be able to sleep well. And at times when the house is so crowded feeding becomes a problem. It could have about 7 – 8 people. I have said some houses have one room, others about two rooms and a parlour, and the upper camps have about three rooms and a parlour. The houses given by contractors are a room to each person. They give them houses but they are many in a room.”
Leisure activities, for the most part, were seen to occur in late afternoons, evenings and weekends (i.e., non-work time). Leisure activities included both indoor and outdoor games, TV viewing, radio listening, talking, attending or participating in soccer and other field sports, and going to video clubs (commercial spaces purposely designed for viewing, at a fee, video films). Within each of the camps at least one bar existed, but in most several bars and open places designated for drinking and social interactions were present. The combination of large numbers of people, bars and market outlets, as well as the availability of electricity, sometimes pipe-borne water, and playgrounds, appeared to draw adjacent non-plantation populations into the camps during leisure hours. Dancing spots were available in some of the camps, but in most cases bars had room for dancing. The entertainment allure to non-plantation populations is described by a male key informant in the following way: “Some people come here to visit their relatives. Others come here during pay days. Many visitors come here to enjoy with us on pay days….Many of them are attracted by money…. . We are very simple, we like to entertain visitors, give them food and drinks, we do not send away visitors….They come here because the camp is the same like the village, we have off licenses, and we have clubs. Most of the clubs are opened on pay days and on quinzieme (day of advance payment).
Knowledge and concerns about HIV
While participants indicated that their communities were being negatively affected by HIV and other sexually transmitted diseases, they were more likely to voice health concerns about malaria, gastrointestinal conditions (e.g., diarrhoea, typhoid, worms, gastritis, dysentery), yellow fever, and skin diseases and disorders (e.g., filaria, fungi, scabies, eczema). Participants indicated that low awareness or knowledge about HIV as well as of sharp objects (blades, needles, shaving machines, syringes) increased risk for HIV transmission and acquisition. Unprotected sex with multiple partners, however, was viewed as the primary reason for people in the camps becoming HIV infected. Participants explained that the disproportionate number of men in the camps was the cause of frequently overlapping sexual relationships where the sharing of female sexual partners was mutually and socially tolerated or benignly overlooked. In some instances, sharing of partners was in the context of prostitution, which was also identified as a key contributor to the spread of HIV. A male focus group participant stated, “In this community, we have many women here who depend on sex to pay their house rent, food and other things. We simply mean that, there are women who, after six or seven o’clock, they take their bath and move around to look for boys who can propose them 1000, 500 or any amount of money….Most of them are prostitutes. They only depend on boys’ money to pay their rent and other things….Here we have about 700 boys for 200 girls”.
The ABC prevention messages (abstinence, be faithful, use condoms) resonated in participants’ responses about what plantation workers and residents could do to avoid HIV infection. They, however, acknowledged that it was difficult to adhere to such principles and practices. They mentioned that condoms were not readily available in the camps. Moreover, condoms were viewed as decreasing sexual pleasure, being tainted with HIV (in particular those containing lubricant), and not truly reliable in preventing sexually transmitted diseases. Study participants further described condom use as complex, explaining that an overriding sexual urge at foreplay often overshadows the necessity for condom use and risk reduction during sexual encounters. One male focus group participant explained, “I will talk as one of the young people who like to participate in those kinds of things. As we do here, if we see a new girl, we try to contact her and bring her closer to us and when our mission is fruitful we have sex with her. So when we are going to have sex with her, we don’t even know how far she came, we don’t know which kind of disease she brought, and we also do not have the time for condom. Because we have shortage of girls, you will only hurry to sex and go, and sometimes since it is difficult to get girls, another boy may see her coming out of your house or room and he too will take her and go with her to his own corner……. The girl can have sex with 10 men as I earlier said. So we don’t know the kind of disease that she can bring and distribute to us.”
Another male focus group participant indicated that “abstinence which has to do with love is one of the most difficult things to observe; this is because love always ends with sex. And for the use of condom….in French they say ça freine le mouvement -- it obstructs movement, which is like it reduces pleasure. So I think that is the hardest…. The sexual aspect is difficult because they feel when they use a condom they do not experience the real thing.”
Perceptions of research and HIV research participation
Before sharing their thoughts on facilitators and barriers to taking part in HIV research, participants were asked to provide their definitions of the word research. Understandings of the term ranged from an abstract concept (“know more about something”) to a more applied one (“looking for ways to prevent health problems” or “bringing development or improvement”). Overall, one-fourth of study participants reported prior participation in research. The remaining participants indicated that familiarization with public health interventions, namely HIV sensitization and immunization campaigns, was more common. For some, the distinction between participation in public health interventions and research was unclear. Within this context, general attitudes towards HIV research centred around three key themes: hope, opportunity, and wariness (Table ). While HIV research was viewed as promising in treating (curing) and ultimately eliminating the spread of the virus and potentially improving normative knowledge and attitudes about the disease, participants voiced scepticism about the practical value of research outcomes, specifically in terms of the availability, access, and sustainability of treatment services.
FGD and KII participant’s perceptions about community-held attitudes toward HIV research express1ed by plantation FGD and KII participants, August-October 2006
Community participation facilitators
Participants also stated that HIV research should focus on improving the general welfare of the community as opposed to restricting itself to merely extracting information from it. As stated by a female key informant, “Research participants want to feel they are better off than they were before research was introduced to them.”. Another male focus group participant reflected that community rejection of HIV research may result from a perception that this is just a “dry academic exercise”.
Protecting the personal information of participants, especially those infected with HIV, was also regarded as a strategy that could encourage participation in HIV research in their community particularly if HIV testing is part of the research procedures. Study participants recommended that other diseases such as malaria, typhoid, and STIs be integrated into the HIV research process to reduce stigma for participants.
Participants indicated that researchers should expect to provide incentives at both the individual- and community-level. The absence of incentives or anything of immediate benefit to participants was perceived to discourage participation. Recommended individual incentives included provision of free drug samples, condoms, and monetary reimbursement. Participants framed suggestions for community-level incentives based on their personal assessment that the conditions at camp health facilities were unacceptable, thus improving the health infrastructure with quality services would likely motivate many to take part in research.
Participants indicated that HIV research that took into account community insights as part of the planning and implementation process could better integrate critical elements of respect, trust, empathy from researchers, and meaningful communication. Participants remarked that broad-based acceptability of research in their community will depend on how researchers communicate their goals to the community. Finally, acceptance of HIV research in plantation communities was viewed as requiring assurances that disruptions to “normal everyday life” would not occur.
Community participation barriers
Participants’ responses regarding barriers to HIV research participation centred on HIV testing issues. We identified five subthemes associated within a broader theme of HIV testing fears: (1) apprehension that test results were likely to show infection; (2) dismay that people would be unable to cope with receiving HIV-positive or conflicting test results (i.e., unmatched results from parallel rapid HIV test); (3) concerns that HIV testing would be forced upon research participants against their will; (4) unease that those taking part in the research would be required to personally cover the cost of expensive HIV tests; and (5) worries that HIV testing efforts were being disguised as research.
The time-related costs were also considered as possible deterrents to research participation. It was perceived that people would not take part in research if it interfered with their work schedules, was considered a waste of time, or took them away from other responsibilities (e.g., their farms). In one female focus group, we heard that “research is for idle people” and without reimbursement for transport and other incentives “people preferred to stay idle in their houses rather than go there and waste their time”.
Participants indicated that prior negative interactions with healthcare providers and staff might discourage some plantation members from taking part in HIV research. They often talked of their own or other’s experiences where healthcare workers had shared personal and confidential information with others in the community. Several indicated that “it is necessary to be discreet” and to know how to keep participants information “secret”. Some participants said that “after having done the test, one [the doctor] starts to speak badly about you”. Moreover, concerns that care and treatment services would not be available, were costly, or were of poor quality were also discussed.
Lastly, we identified two barriers that focused on behaviour. Participants expressed concern that researchers would encourage, if not outright require, that persons enrolled in studies take part in HIV-risk behaviours (e.g., adopt or maintain a sexually promiscuous lifestyle) to help determine whether an intervention effectively prevented, treated, or cured HIV infection. Concerns were voiced that people would be experimented on and treated as research guinea pigs. One male FGD participants stated,
« For example, I do the AIDS test, and I am told that I am seropositive, then I am left like that and I go home !…..I will prefer that after I test positive, you should call me and say, ‘my brother as you are positive like this, this is not the end of the world. Life is still going to continue for you, you are going to live. And then you do something to safe my life.’ So this is where the problem is, people want to feel secured”.
Conversely, some participants stated that requiring people from abstaining from alcohol use and sex would likely discourage research participation. Table summarizes key facilitators and barriers to research participation identified by study participants.
FGD and KII participant’s perceptions on what their communities would view as facilitators and barriers to HIV research participation, August-October 2006