The Qualitative Methods Journal Club discussed a paper on risk behaviours for HIV reported by a cohort of Black women in the United States. The ‘syndemics framework’ revealed how health and social inequalities can exacerbate drug and alcohol problems, HIV risk, and personal vulnerability. The study was important given the under-representation of women within studies of substance use, and in many ways the disproportionate impact of HIV on Black women in the US.
About this month’s Journal Club
The article (available here) was discussed online (MS Teams) within the National Addiction Centre, Institute of Psychiatry, Psychology & Neuroscience at King’s College London with 7 attendees (from King’s College London, Queen’s University, Belfast and the University of Exeter). Stephen Parkin (National Addiction Centre, KCL) presented and led the discussion.
Summary of the article
This article presents a qualitative study of alcohol and drug-related HIV-risk behaviours reported by a cohort of Black women in the Milwaukee area of Wisconsin, USA. The study was part of a wider research programme that explores pre-exposure prophylaxis (PrEP) uptake and adoption (including barriers and facilitators) among Black women at risk of HIV.
The article reports on a theory-driven, longitudinal, qualitative study in which Nydegger and Claborn describe interviews with 31 women at four points in time throughout a 6 month period. Interviews were held in the participants’ accommodation or in offices within the relevant university campus. The interviews were subject to thematic content analysis in which the authors were able to track changes to the participants’ (collective and individual) experiences of alcohol and drug-related HIV risk behaviours from the corresponding transcripts.
Analysis developed two distinct groups of participants: those considered to be in recovery from drug of choice and those who used their drug of choice throughout the study. Additionally, and more significantly, each of the two groups were impacted by various health and social factors (i.e. the syndemics framework and associated theory underlying the study) that had a corresponding impact upon personal vulnerability and HIV risk-related behaviours.
The authors’ conclusions from their study included the view that “substance use interventions tailored to vulnerable Black women should consider including trauma-informed interventions and support groups that address the structural, social, and individual factors to better serve their needs.”
Discussion of the article
The SSA QMJC enjoyed a full and varied discussion about many aspects of this article and especially with regard to why this should be regarded as a good example of a qualitative research paper. These included ‘research topic’, ‘methodological design’, ‘methods used’ and ‘presentation/reporting of data’. These are summarised further below.
“Although we may have anticipated that Black women who use alcohol and other drugs are ‘disproportionately affected by health disparities’, we were alarmed to learn that ‘Black women’s HIV diagnosis rates are 15 times higher than White women, and is among the leading causes of death among Black women in the US’.”
All discussants at the meeting were based in UK universities and many of us were shocked or surprised at the contextual background of Nydegger and Claborn’s study of Black American women. Namely, although we may have anticipated that Black women who use alcohol and other drugs are “disproportionately affected by health disparities”, we were alarmed to learn that “Black women’s HIV diagnosis rates are 15 times higher than White women, and is among the leading causes of death among Black women in the US”. This led us to discuss the research topic from the perspective of ‘gender’ and the overall (global) under-representation of women within studies of substance use.
Nydegger and Claborn were therefore applauded for addressing the topic of HIV-risk behaviour from a purely female perspective – particularly given the aforementioned epidemiological background to the study. In turn, this led to a discussion of the way in which the wider research literature typically portrays women who use drugs as those who are exploited, manipulated, controlled and marginalised by other people who use drugs (typically, male) or by structural constraints embedded within policy, practice and treatment services (including and extending to the legal system, social services and child protection agencies). This article was therefore considered to further add to this literature and knowledge due to the way in which the authors provide empirical evidence to support structural and inter-personal inequality associated with women’s substance use.
In addition, and as noted by Nydegger and Claborn, ‘most evidence-based HIV prevention interventions have been developed and targeted towards White men who have sex with men’. As such, we as a group felt that such a study was a great example of how research may be designed to be inclusive of underserved, under-represented populations, with experience of substance use issues and other ‘adverse life events’.
“This article was considered exemplary in how to report upon the methodological design of a qualitative study due to the clear links between topic, research, findings, conclusions with corresponding applied, real world, recommendations.”
As a group we were very impressed with the methodological design of the study. That is, the authors had a clear research question to answer (relating to risk and vulnerability amongst Black women), informed by geographical, cultural and epidemiological contexts (within USA), with which they attempted to answer via a theory driven study (namely, the syndemics framework, as developed by anthropologist Merrill Singer approximately 20 years ago) that prioritised qualitative inquiry (semi-structured interviews) in a longitudinal design (4 interviews over an extended period of 6 months) with a cohort of the target population (vulnerable Black women with recent experience of substance use and unprotected sex).
In addition, the analytical framework appeared to be consistent with this methodological design due to its focus upon thematic content analysis – (in which thematic analysis appears to have prioritised various structural and inter-personal components of the syndemics framework and content analysis appears to have focused upon the content of each of the four individual interviews held with the 31 women).
Furthermore, throughout the article, Nydegger and Claborn make obvious links and continuous connection to the topic of inquiry within their methodological framework. As such, this article was considered exemplary in how to report upon the methodological design of a qualitative study due to the clear links between topic, research, findings, conclusions with corresponding applied, real world, recommendations.
“Given the wider, aforementioned, under-representation of women in studies of substance use/treatment, the group were … especially impressed with the reimbursement of childcare costs to enable women to attend an interview meeting”.
Several of the group were impressed by the longitudinal interview design of the study and the way in which data could be generated over an extended period of time instead of during a single, one off (‘snapshot’) interview. Others were impressed with the way in which recruitment (and the two phase screening) occurred and the locations of interviews being in participant’s homes. (Although the use of third party researcher as observer did raise questions about how this may have affected participant responses – and whether it resulted in people being less open in their responses).
Given the wider, aforementioned, under-representation of women in studies of substance use/treatment, the group were also impressed with the incremental reimbursement system for each interview that is described in the article (and we were especially impressed with the reimbursement of childcare costs to enable women to attend an interview meeting).
Overall, the group held the view that the methods described in the article provided an example of good practice regarding the recruitment, screening, payment and participation of underserved populations in qualitative studies of sensitive issues.
‘Presentation/reporting of data’
“We were impressed with … the way in which theory, experience and illustration are succinctly compacted together to aid understanding and comprehension of the overall empirical findings relating to syndemics theory.”
The presentation of qualitative data in this article was considered a further example of good research practice – especially for those who are perhaps new to writing up detailed, in depth studies of complex issues. In particular, we were impressed with Table 2 in this article and the way in which theory, experience and illustration are succinctly compacted together to aid understanding and comprehension of the overall empirical findings relating to syndemics theory. This was considered good practice in representing qualitative data in academic texts – as the tabular format has the advantage of being able to include more detail than perhaps a descriptive/contextualised paragraph on a given issue. However, there was also a discussion that focused on the use of the term ‘Representative Quote’ as a Table 2 column heading, in which members of the group would have liked to have known more about the authors’ definition of ‘representative’ in this regard.
Finally, as a bonus ‘fun’ item, the group also found the use of the Yin Yang symbol (☯ meaning ‘balance’) after each author names (in the title), to indicate equal contributions, as a particularly novel inclusion – and much more symbolically relevant than the customary asterisk used in most other journals. We did not know if this was of the design of the journal or authors, but it was noted by the group as a great way of indicating equal contribution to an academic research article.
About the article
Nydegger, L.A., and Claborn, K.R., (2020) Exploring patterns of substance use among highly vulnerable Black women at-risk for HIV through a syndemics framework: A qualitative study. PLoS ONE 15(7): e0236247.
The article can be accessed here.
Author response to discussion (added as postscript)
Thank you for the in-depth summary and discussion of the aforementioned manuscript. I appreciate the discussion on how vulnerable women, especially Black women, are often overlooked in HIV-related research, as well as the methods.
In response to the concern regarding a research assistant present during interviews, I agree that it could have had an impact. However, it was a rule that post-doctoral researchers must be accompanied by a research assistant when in the field. To combat the impact as much as possible, I tried to bring the same research assistant for all 4 interviews so the participants were comfortable with us both. I also asked participants if they were okay with the presence of the RA or if they preferred that they stay in another room. Additionally, given the longitudinal design, I developed a strong rapport with participants. While participants may have not divulged all the information asked, given the breadth and depth of interview content we were still able to ascertain pertinent data.
Thank you for the comment regarding the word “representative” in Table 2. Our definition was that the quote encompassed the findings from numerous participants. The yin yang symbol is a design by the journal – I thought it was a great representation as well!
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