The Impact of Aids Psychological and Social Aspects of HIV

Infection, 1st Edition

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 v

Samuel R.Friedman, Alan Neaigus, Benny Jose, Richard

Curtis, Marjorie Goldstein, Jo L.Sotheran, John Wenston Carl
A.Latkin and Don C.Des Jarlais
8. Amphetamine Injecting Women and their Primary Partners: An 114
Analysis of Risk Behaviour
Hilary Klee

GENDER ISSUES
9. Recognizing and Countering the Psychological and Economic 126
Impact of HIV on Women in Developing CountriesCatherine
Hankins
10. Caregiving and the Natural Caregiver of the Person Infected with 135
HIV
Mary Reidy
11. Children Born to Mothers with HIV/AIDS: Family Psycho-Social 147
Issues
Robyn L.Salter Goldie, Dale J.DeMatteo and Susan M.King
12. Young Women and HIV: The Role of Biology in Vulnerability 157
Mike Bailey
13. HIV Testing in the Antenatal Clinic: Setting up a Counselling and 168
Testing Service
Jean Meadows, Tracey Chester, Paul Lewis and José Catalán

CARE AND TREATMENT

14. Bridging the Gap between Science and AIDS Service Provision 179
Edward King
15. Nurse-Counsellors’ Perceptions Regarding HIV/AIDS Counselling 187
Objectives at Baragwanath Hospital, Soweto
Joanne Stein, Malcolm Steinberg, Cliff Allwood, Alan Karstaedt and Pierre
Brouard
16. A Family System Approach for Community Health Nursing: 195
Balancing the Complexity of Family HIV/AIDS Care with Human
Compasssion and Moral Agency
Amandah Lea
17. Human Immunodeficiency Virus (HIV) Infection in the Brain: 208
Pathological and Clinical Features
Ian P.Everall
18. Ethical Dilemmas for Psychiatrists: Assisted Suicide in AIDS 219
vi

Alexandra Beckett
19. HIV Infection in Psychiatric Inpatients 230
Jose L.Ayuso-Mateos, Ismael Lastra Martínez, Francisco Montañes
Rada and Juan J.Picazo de la Garza

INDEX 240
 Preface

The psychological and social implications of HIV infection became apparent

from the start of the epidemic. Not only was HIV a condition with an
unpredictable course, which often had fatal consequences and was therefore
likely to lead to psychological distress and social disruption—in addition, the
fact that in developed countries HIV infection affected individuals already
stigmatised and in developing countries typically reached people facing adverse
economic and social conditions, meant that this new syndrome was likely to have
a substantial psychological and social impact beyond its purely medical and
biological implications. Furthermore, the absence of effective treatments to treat
the infection or prevent its transmission has meant that psychological and social
interventions have provided the main method for prevention of the spread of HIV
by focusing on behavioural change.
The psychological response to the HIV epidemic has evolved and grown
through a number of phases over the last fifteen years. At first, behavioural
change was seen as the main focus of action and much effort was spent on public
education and in the dissemination of information. A very strong strand at the
outset of the epidemic was the concern about the rights of individuals with HIV
infection, and a good deal of effort was put into fighting discrimination and
stigmatisation. Next came the realisation that behaviour change and its
consequences were a much more complex process than anticipated, and this
occurred in parallel with increased interest in counselling and support, both in
relation to HIV testing and to the provision of support for individuals and
families affected by HIV. New areas of interest have developed more recently
— first, concerns about the neuropsychological consequences of HIV infection,
and second the issue of access to treatment, and in particular the involvement of
people with HIV infection in the setting up of the agenda for treatment trials and
access to sources of care. Finally, as the global nature of the epidemic has become
clear and the epidemiological patterns of infection have begun to change, the role
of socio-economic factors has become more prominent. While the emphasis of
each one of these areas of concern has changed over the years, the relevance of
each has not been in doubt.
From the start of the epidemic efforts have been made to bring together the
medical, psychological and social dimensions of HIV, in some ways providing a
viii

model for other medical disorders and for psychosocial interventions.

International AIDS conferences soon became a forum for integration of effort
and communication between groups working in developed and developing
countries. An example of such international co-operation has been provided by
the experience of the International AIDS’ Impact Conferences, which have
focused on the interaction between psychological, social and biological factors in
HIV infection.
This volume highlights major themes by including papers based on the AIDS’
Impact Conferences, the first of which was held in Amsterdam in 1991, the
second in Brighton, UK, 1994, and the third of which is scheduled for Melbourne
in 1997.
The contents of this volume are structured in four thematic sections which
emerged from the Brighton Conference: Prevention, Drugs, Gender Issues and
Care and Treatment. Each section contains a selection of papers which illustrate
the complexity of the subject and which review a particular topic or highlight a
specific form of intervention which has important theoretical and practical
implications.
The Prevention section is introduced by Manderson and colleagues who
present a thorough review of research into the use of condoms in heterosexual
sex, examining the methodological problems involved in the field, and then
detailing the factors that contribute to or hinder condom use. Wanigaratne and co-
workers complement Manderson’s chapter with a practical review of group
interventions to help gay men initiate and maintain safer sexual behaviour,
illustrating the difficulties involved in carrying out and evaluating this kind of
preventive work. Svenson, Johnsson and Hanson in Chapter 3 describe the
process of developing peer education within a university campus to reduce the
risk of transmission of HIV, while Gadd and Goss illustrate the process of HIV
education in the workplace and the difficulties encountered in the work setting.
The role of the media in providing information (or misinformation in many
cases) and in shaping attitudes to HIV infection in those affected by it is
examined by Cunningham and co-workers in the final chapter of the Prevention
section through the discussion of ten years of AIDS images in the Puerto Rican
press.
In the second section on Drugs three chapters focus on the way the HIV
epidemic has spread amongst drug injectors. Stimson provides compelling
and disturbing evidence about the spread of HIV infection in South-East Asia
and highlights the social, economic and political factors involved. Friedman and
colleagues working in New York provide detailed ethnographic observations
concerning the factors and processes that contribute to risk behaviours and risk
of HIV infection in drug injectors, as well as the identification of interventions
likely to make a contribution to the prevention of spread in this group of
individuals. Finally, Klee discusses the lifestyle of women who inject
amphetamines and their risk behaviours in the rather different setting of
northwest England.
 ix

The next section is devoted more specifically to Gender issues. Hankins

focuses her discussion on the psychosocial and economic impact of HIV
infection on women living in developing countries who may already be facing
higher levels of adversity than their partners or than women in developed
countries. The impact on caregivers in developed countries is reviewed by
Reidy, and the consequences for children born to mothers with HIV infection by
Goldie and co-workers, who carried out an empirical study involving twenty five
parents and thirty six children who lived with one or both parents. Bailey gives a
biological perspective of the risk of HIV infection in young women. Finally,
Meadows and co-workers discuss the setting of an HIV counselling and testing
service in an antenatal clinic in London, illustrating some of the difficulties and
opportunities such a service can face.
The final section of the book presents current thinking on the Care and
Treatment aspects of HIV disease. King, in a seminal paper, highlights the need
to ensure that scientific progress and research developments in HIV can be
accessed meaningfully by those who require them. Stein and co-workers working
in Soweto give a detailed illustration of the work of nurse-counsellors in an
urban area in South Africa, highlighting the need for training and continuing
supervision. Lea illustrates the work of community nurses with families in two
very different settings, Edinburgh in Scotland, and a rural community in British
Columbia. Everall contributes an up-to-date review of the effects of HIV
infection in the brain, reviewing both clinical syndromes such as HIV-associated
dementia and the neuropathological consequences of the infection. Some of the
psychiatric consequences of AIDS are examined in the next two papers. Beckett
reviews some of the ethical dilemmas that can face not only psychiatrists but also
other mental health professionals working in the field of HIV, particularly in
relation to euthanasia and physician-assisted suicide. Finally, Ayuso-Mateos and
co-workers provide empirical information on the prevalence of HIV infection
among acute psychiatric admissions to a psychiatric unit in Madrid, highlighting
the implications for the mental health services.
Although each chapter provides a self-contained perspective on a particular
topic, it is important to consider what is their combined message. As became
apparent in the closing talks in Brighton, ‘the whole was more than the sum of
the parts’. The complexities of prevention and care cannot be disentangled from
the reality of social, political, economic and gender issues. It is necessary
periodically to review the multi-faceted aspects of the impact of AIDS. We,
the Editors, hope that this sample of papers will afford the reader the opportunity
to consider a number of bio-psycho-social issues posed by HIV and will contribute
to the understanding of its impact on individuals and societies throughout the
world.
José Catalán
Lorraine Sherr
Barbara Hedge
 About the Editors

José Catalán, Reader in Psychiatry and honorary Consultant Psychiatrist at the

Charing Cross & Westminster Medical School, University of London and
Riverside Mental Health Trust has been involved in research into the mental
health aspects of HIV infection for over ten years. He is also in charge of the
psychiatric services for people with HIV infection at the Chelsea & Westminster
Hospital which is the largest centre in the UK for the care of people with HIV
infection.
Lorraine Sherr, Senior lecturer, Clinical Psychologist at the Royal Free
Hospital School of Medicine. An editor of the international journal AIDS Care
and Psychology Health and Medicine, she has travelled to Africa, Canada and
the USA as a Churchill Fellow to conduct research into AIDS and HIV and
participates in numerous national and international research and clinical
initiatives.
Barbara Hedge, Consultant Clinical Psychologist at St Bartholomew’s
Hospital and honorary senior lecturer in psychology at St Bartholomew’s and the
Royal London School of Medicine and Dentistry, is responsible for the clinical
psychology services for people with HIV disease at St Bartholomew’s and the
Royal London Hospitals. For the last ten years she has studied the psychosocial
factors affecting the quality of life of individuals infected with HIV and their
partners and has been involved in the running of workshops and counselling
courses in Africa and Eastern Europe.
 Notes on Contributors

Cliff Allwood is principal psychiatrist at Tara Hospital and acting head of the
Department of Psychiatry at the University of the Witwatersrand, South
Africa.
Jose L.Ayuso-Mateos, professor of Psychiatry, Clinical and Social Psychiatry
Research Unit, Hospital Universitario Marqués de Valdecilla, Cantabria
University, Spain.
Mike Bailey has worked as a consultant in the UK and in Africa and Asia for
ODA, EC, UNDP, UNICEF, WHO and non-governmental organisations such
as Save the Children and OXFAM. He is an honorary lecturer in the Centre
for International Child Health at the Institute of Child Health, London, UK.
Alexandra Beckett is a graduate of the University of Michigan Medical
School. She completed her residency training and a research fellowship in
Psychiatry at Massachusetts General Hospital. She is an assistant professor of
Psychiatry at Harvard Medical School. Since 1991, she has served as director
of the HIV Psychiatry Service at Beth Israel Hospital in Boston,
Massachusetts. She is also the principal investigator of a study on ‘The
Epidemiology of Suicidal Ideation in AIDS’ funded by the American Suicide
Foundation.
Andrew Billington is health adviser at Camden & Islington Community
Health Service NHS Trust, London, UK.
Pierre Brouard is a senior HIV/AIDS counsellor and counselling trainer at
the AIDS Training and Information Centre, South Africa.
Tracey Chester is the HIV specialist counsellor for the Chelsea &
Westminster Health Care Trust Maternity Unit, UK.
Ernest L.Cunningham is professor of Medicine in the School of Medicine at
the University of Puerto Rico.
Ineke Cunningham is professor of Sociology and director of the HIV/AIDS
Research & Education Center at the University of Puerto Rico, Río Piedras
campus.
xii

Richard Curtis has over 10 years of experience in studying the ethnography

of drug use. His research has included work on HIV epidemiology and HIV
prevention as well as on social networks among drug injectors.
Dale J.DeMatteo has been involved in research for ten years at the Hospital
for Sick Children in Toronto, Canada.
Ian P.Everall is MRC clinician scientist fellow and senior lecturer in
Psychiatry at the Institute of Psychiatry, De Crespigny Park, London, UK.
Samuel R.Friedman is a senior research fellow at NDRI (National
Development and Research Institutes Inc.), New York City, USA.
Karen Gadd is a lecturer in Health Studies at the University of Central
Lancashire, UK.
Juan J.Picazo de la Garza, Chairman, Department of Microbiology, Hospital
Universitario San Carlos, Madrid, Spain.
Robyn L.Salter Goldie works with families in the HIV program at the
Hospital for Sick Children, Toronto, Canada and is currently principal
investigator on a national study of Canadian families living with HIV based on
these pilot study results.
Marjorie F.Goldstein is a principal investigator at NDRI, and is an
epidemiologist and health educator. She received her MPH from Johns
Hopkins University and her PhD from Columbia University. Her research
interests include the behavioural aspects of HIV prevention, the role of social
networks in risk behaviour, and the processes of obtaining drug treatment and
HIV-related services.
David Goss is professor of Organisational Behaviour at the University of
Portsmouth Business School, UK.
Catherine Hankins is a community medicine specialist in the Infectious
Diseases Unit of the Montreal Regional Public Health Department, Canada
and an associate professor in the Department of Epidemiology and
Biostatistics of McGill University.
Bertil S.Hanson is head of the division of Social Medicine and Community
Health Programmes at the Department of Community Medicine, Lund
University, Sweden.
Don C.Des Jarlais is the director of research of the Chemical Dependency
Institute at Beth Israel Medical Center, professor of Epidemiology and Social
Medicine at Albert Einstein College of Medicine, and a senior research fellow
at the NDRI. As a leader in the fields of AIDS research and intravenous drug
use, his bibliography includes over 200 publications, and he has made 1000
presentations on AIDS and AIDS-related topics that include plenary addresses
at the third and fourth International Conferences on AIDS. He has served on
numerous advisory committees for the CDC, NIDA, the National Commission
on AIDS, and the National Academy of Sciences. He is Vice Chair of the
Committee of AIDS Research and the Behavioral, Social, and Statistical
 xiii

Sciences that was established by the National Research Council of the National
Academy of Sciences.
Kent Johnsson has been the health promotion nurse at Lund University’s
Student Health Programmes at the Department of Community Medicine, Lund
University, Sweden.
Benny Jose is a project director at the Institute for AIDS Research, National
Development and Research Institutes Inc., New York City, USA.
Alan Karstaedt is head of the HIV/AIDS Clinic and the Infectious Diseases
Unit at Baragwanath Hospital, South Africa.
Edward King is director of the gay men’s HIV prevention organisations; Gay
Men Fighting AIDS and Rubberstuffers.
Susan M.King is Paediatric Infectious Diseases consultant and assistant
director of the HIV program at the Hospital for Sick Children in Toronto,
Canada.
Hilary Klee is professor of Research Psychology at the Manchester
Metropolitan University, UK and director of the Centre for Social Research on
Health and Substance Abuse (SRHSA).
Carl A.Latkin is a social psychologist on the faculty of Johns Hopkins
University School of Public Health. His primary interests include the social
context of disease transmission and HIV/STD prevention using social network
and social influence models.
Amandah Lea is currently a doctoral nursing student at the University of
British Columbia in Vancouver, Canada. For more than a decade, she was a
community health nurse for First Nation villages located in rural British
Columbia.
Paul Lewis has been a midwife for over 14 years and is currently academic
head of Midwifery and Women’s Health at Bournemouth University, UK.
Lenore Manderson is professor of Tropical Health (Anthropology) at the
Australian Centre for International & Tropical Health, University of
Queensland, Australia.
Ismael Lastra Martínez, research fellow in the Clinical and Social Psychiatry
Research Unit, Hospital Universitario Marqués de Valdecilla, Spain.
Jean Meadows is a research psychologist in the Psychological Medicine Unit
of the Chelsea & Westminster Hospital, UK.
Alan Neaigus is principal investigator at National Development and Research
Institutes Inc., in New York City, USA and co-investigator on the Social
Factors and HIV Risk project and the HIV among Youth project.
Francisco Montañes Rada, resident, Department of Psychiatry, Hospital
Universitario San Carlos, Madrid, Spain.
Kiruba Rajanayagam was assistant director of the Red Cross Blood
Transfusion Services of Papua New Guinea, and in Australia was briefly
xiv

attached to the Tropical Health Program, University of Queensland as a

research assistant. She is currently a full-time general practitioner.
Mary Reidy is full professor at the Faculty of Nursing, University of
Montreal, Canada. She is also scientific director of a nursing research team
(AIDS: care and caregivers, funded by FRSQ). She has received considerable
funding, and has extensively published and presented conferences regarding
the psychosocial and the family/natural caregiving aspects of those living with
AIDS.
Lynnette Rivera-Rodríguez and Sigfrido Steidel-Figueroa are law students
and research assistants in the HIV/AIDS Research and Education Center at the
University of Puerto Rico, Río Piedras campus.
Jo L.Sotheran is a senior project director at NDRI, where she currently
directs a multi-method study of injection practices in a New York
neighbourhood. Her research interests in relation to networks centre on
injection groups and on domestic groups among injecting drug users.
Joanne Stein is a senior researcher in the National AIDS Research
Programme of the Medical Research Council, South Africa.
Malcolm Steinberg is leader of the National AIDS Research Programme of
the Medical Research Council, South Africa.
Gerry V.Stimson is professor of the Sociology of Health Behaviour and
director of the Centre for Research on Drugs and Health Behaviour, Charing
Cross & Westminster Medical School, London, UK.
Gary Svenson has worked full-time since 1989 with the biopsychological
aspects of HIV infection at the Department of Infectious Diseases, University
Hospital of Lund, Sweden.
Lee Chang Tye is a consultant specialising in the field of Health Promotion
Evaluation, currently evaluating a workplace health promotion model at
Griffith University, Australia.
Shamil Wanigaratne is consultant clinical psychologist & head of Clinical
Psychology at Camden &; Islington Substance Misuse Service, National
Temperance Hospital, London, UK.
John Wenston was principal research associate at NDRI. Other HIV-related
research he has carried out centres on utilization of HIV treatment, and on the
effects of syringe exchange on risk reduction.
Malcolm Williams is principal social worker St Christopher’s Hospice
London, UK, working with change, loss and bereavement.
 1
Condom Use in Heterosexual Sex: A Review
of Research, 1985–1994.
LENORE MANDERSON, LEE CHANG TYE AND KIRUBA
RAJANAYAGAM

INTRODUCTION
The condom has been and will remain the major technology to limit sexual
transmission of HIV in the foreseeable future, and thus issues related to its
acceptance and use are a priority. Since the isolation of HIV, the establishment
of its primary modes of transmission, and the development of HIV/AIDS
prevention programs, hundreds of studies have been undertaken on the male
condom. These include cross-sectional KABP (knowledge, attitudes, behaviour
and practices) studies of condom and/or other HIV prevention strategies, condom
interventions and evaluations, and recently, ethnographic studies that document
the social, cultural and interpersonal contexts of safer sex and condom use. This
paper surveys articles published in biomedical and social science journals from
1985 to early 1994.1 In reviewing this literature, we examine critically the
research assumptions and construction of categories used, and draw attention to
inconsistencies in findings and inferences.
Factors associated with the use of condoms do not apply universally across
cultures or populations. A variety of issues influence acceptability, frequency
and consistency of use among the study populations defined as ‘at risk’, although
the conceptualisation and operational definitions of risk and the definition of the
populations are themselves often problematic. Reasons for non-use of condoms
by heterosexual youths, for example, are different from those of homosexual/

1 Since the review concentrates on publications in scientific journals, the review is

necessarily partial. Over the period 1989–1993 alone, a restricted search of MEDLINE
(condoms + HIV + heterosexual sex) identified 558 articles; SOCIOFILE lists a total of
204 articles to 4/1994; and PsycLIT includes 372 papers for the period January 1987—
March 1994. There is some overlap in citations, but even so the relevant literature is
extensive and space is a major limitation of a comprehensive survey. We excluded much
of the material informally published and distributed, and books and chapters in books are
also largely excluded. Further, the literature relating to AIDS is generated at an
exceptional pace compared with other areas of public health and medicine, and hence any
review is inevitably out-of-date by the time of its completion.
2 LENORE MANDERSON ET AL.

bisexual adult men. Similarly, reasons for non-use across cultural and national
boundaries (for instance, between Americans and Zaireans) are marked, although
there is some interesting concordance too. Variations in sexual situations and
contexts have a strong influence over condom use. Here, we largely limit our
discussion to the male condom, heterosexual sex, and industrialised countries,
although for comparative purposes we allude to other condom research. The
studies on which we base this review reflect research predominantly conducted
in the United States and Europe. There is far less published which addresses
issues of HIV prevention in developing countries; this bias is not surprising
given the concentration of researchers in the United States and the relatively
early response by funding agencies to support research and behavioural
interventions.2 The papers which we describe below, their subject matter,
methodological approaches, conceptual frameworks and research questions
suggest that they are reasonably typical of the literature, although some of the
work being conducted within the humanities (e.g. in anthropology and cultural
studies) has a very different focus (e.g. Clatts & Mutchler, 1989; Bolton &
Singer, 1992; Herdt & Lindenbaum, 1992).

POPULATION SELECTION
For research purposes, studies on condom use for AIDS prevention have defined
target populations in line with epidemiological classifications of ‘at risk’
populations (Murray & Payne, 1989). These are not coincident with the target
populations for contraceptive condom use, with the exception of young people,
and there has been little reflection back on that earlier literature in terms of its
possible lessons for HIV prevention. Although the selection of research
populations of condom studies largely reflects the current burden of infection,
the volume of research is not proportionate: within the US, for example, while
men who have sex with men, commercial sex workers and recreational injecting
drug users are disproportionately affected by the disease, ‘heterosexuals’ and
‘youth’ are the most common target populations for research, accounting for
around half of all published studies. Blacks, Hispanics and other ethnic
minorities have been the subject of relatively little research (around 10% of all
studies) despite their disproportionate share of infection (Lesnick & Pace, 1990:
173).
Recruitment procedures vary considerably among the studies. Research
conducted with ‘at risk’ populations often draws participants from groups that
have been labelled and stigmatised, e.g. as prostitutes, homosexuals, alcoholics,

2 For a discussion of Australian government responses to the epidemic and to research

funding, see Manderson (1994). The preponderance of publications from USA-based
researchers reflects the research culture of different places, with relatively more or less
emphasis on publishing, as well as the easier task of researchers with facility in English to
successfully submit their work for publication.
 CONDOM USE IN HETEROSEXUAL SEX 3

or drug users (or ‘abusers’), who are usually recruited in urban areas where the
behaviour by which they are identified is presumed prevalent. Hence drug users
tend to be recruited through clinics or street locations (e.g. Watters et al., 1990),
adolescents/ youth through schools (Mathews et al., 1990) or probation or
remand homes (Wilson et al., 1990), and commercial sex workers from ‘red light
districts’ and similar geographic concentrations. The identification of locales and
the recruitment of participants is frequently undertaken through relevant social
networks such as community service agencies (health/medical clinics), social
organisations, local media, and so on (Valdiserri et al., 1989; Fullilove et al.,
1990) and volunteers are consequently individuals who have self-identified with
the population group or its defining characteristics. By maintaining this focus,
the literature tends to represent these groups as homogenous. The contradictions
in research findings suggests that this is a fallacy, and that there are as many
differences—across class, race, ethnicity, gender, age, and sexual orientation, for
example—as there are commonalities.
Population selection, appropriateness of the research tool, and the context of
data collection limit and at times bias findings. Many of the study populations
have been recruited through opportunistic or convenience sampling, limiting
generalisability. For example, a KABP study among Black and Hispanic students
in the Bronx was conducted because of lack of information of perceptions and
risk factors of transmission of this population, which has a high prevalence of
HIV. The study population, however, was entirely opportunistic: students
attending English language classes in one college, the majority with ‘limited’
proficiency in English, completed a self-administered questionnaire as a
compulsory classroom assignment (Lesnick & Pace, 1990). Other examples of
limitations on population selection (and method) might include the work of de
Graaf et al. (1992), who recruited clients of prostitutes through newspapers and
used ‘snowballing’ to recruit prostitutes direct from workplaces and through
intermediaries and referrals—here the problem is not in terms of population
recruitment per se, but in terms of its limitations when the research aim was to
generate quantifiable data. Contrast this, for example, with the study of Fox et al.
(1993), designed to test the effectiveness of an intervention (through discussion
groups and the distribution of condoms) among commercial sex workers, where
the use of opportunistic sampling was clearly appropriate.
Sample size in the studies surveyed varied enormously. It includes as few as
two (where the notion of ‘sample’ is not appropriate) (Kane, 1990) to over 8000
(e.g. Campbell & Baldwin, 1991; Catania, Coates, Stall et al., 1992). While
sample size is not entirely predictive of method, generally studies with smaller
samples used qualitative methods whilst larger studies used cross-sectional
surveys with a simple, standardised instrument. Although generalizability and
representativeness is a problem even with some of the very large studies, the low
number of respondents in some of the ‘qualitative’ studies is a particular
concern, since these are rarely based in ethnography and ‘qualitative’ often
simply means the use of an open-ended semi-structured interview rather than a