Methodology of the research

Introduction

This study attempts to review the existing links between high-risk groups, migrant workers, people on the move, and the general population. The study focused on the main internal and external migrating populations within Tamil Nadu as a sending and receiving place.

To cover this wide issue it is necessary to use both qualitative and quantitative methods. The methodology of the present research included two stages and involved a variety of qualitative and quantitative techniques.
• A first phase focused on literature review and preparatory missions to review statistical sources and existing research on migration with a view of mapping the main migration flows in the state. The targeted populations were selected for the second phase of the research based on:
o their membership to high risk group;
o their migration status;
o their relation to the migrant population.
• Because informal migration is not systematically reported in official statistics, the researcher established close links with NGOs and field practitioners working on migration issues. As a result of the first phase a breakdown of estimates for the identification of high risk groups, a representative sample by place of origin / transit / destinations, and labour sector were made available. During the 1st phase the researcher also identified specific research tools. Important information regarding the seasonality of the migrations was useful for the planning of the second phase.
• The second phase consisted in field surveys for urban poor migrants labourers concentrated in the slum areas. A preliminary ethnographic observation was conducted which gave valuable input to design detailed in-depth schedule. Five slums were selected in Chennai Metropolitan Area. The schedules were collected from 200 heads of households in each selected slum with a total of 1009 respondents from five slums. The respondents’ age varied between 18 and 49 years. Twenty participatory sessions were conducted for additional qualitative data. It included focus group discussions with different groups of concern like women, children, and elderly people. The study also included focus discussions with key informants like health officials, field practitioners, and policy makers.

Sampling
Define sample population

“Being mobile in and of itself is not a risk factor for HIV/AIDS; it is the situations encountered and the behaviors possibly engaged in during mobility or migration that increase vulnerability and risk regarding HIV/AIDS”.
UNAIDS, 2001.
Population mobility and AIDS.
UNAIDS Best Practice Collection, Geneva.

Past comparative research on demographic behavior in India have in general tended to contrast south India with north India (Dyson, and Moore, 1983; Miller, 1981; Basu, 1997). This comparison is based on the assumption that south India as a whole has a similar social, economic and cultural history (Karve, 1965; Sopher, 1980). However, there are variations between the four south Indian states of Kerala, Tamil Nadu, Andhra Pradesh and Karnataka. Kerala has traditionally been more advanced in terms of human development compared to the rest of south India (see Map 3) (Dre’ze, and Amartya Sen, 1997). Over the last two decades Tamil Nadu has also progressed substantially in economic, social and demographic arenas (Krishnan, 1976; Mencher, 1981; Zachariah, 1984; Caldwell, et al., 1983; Caldwell, 1986; Bhat, and Rajan, 1990; Kishor, 1994; Srinivasan, 1995; Ramasundram, 1995).

NACO’s national strategy on HIV/AIDS mentions that high-risk groups for HIV/AIDS/STI are: CSW- (Commercial Sex Workers), Truckers (truck drivers), Migrant workers, IDU- (Injecting Drug Users), MSM – (Men having Sex with Men). It is defining groups with higher risk behavior as:
• Those having sexual intercourse with multiple partners; for example MSM, SW- (Sex Workers), and persons entertaining unprotected multiple sexual relationship;
• Those sharing inadequately sterilized needles, syringes and other skin-piercing instruments, for example, injecting drug users.

The mobile/migrant population defined in this research is a mobile population exposed to a risk environment. IOM and UNAIDS define mobile populations as followed: truckers, seafarers, transport workers, agricultural workers, itinerant traders, mobile employees of large industries such as mining, oil, forest companies etc., service personnel in the army and civil service.

Both international and national definitions include truck drivers and commercial sex workers in high-risk groups. In the NACO definition, the migrant workers are mentioned as a marginalized group. Migrants are defined by IOM as a mobile people who take up residence or remain for an extended stay in a foreign country.

To ensure that the study covers all aspect of the mobility and HIV/AIDS, it will focus on the population in the slums. Studies done by APAC (APAC, 2002) show that almost all inhabitants’ of slum areas are mobile and at risk of HIV. Problems such as Intravenous Drug Use, Commercial Sex Work are also present in the slums.

To summarize, the research deals with mobile/migrant population in the urban areas concentrated in the slums because:

• The population in the slums is highly mobile;
• The population in slums is working as helpers/service providers for the high risk groups such as truck drivers;
• Risk groups such as Commercial Sex Workers, Intravenous Drug Users and Men who have Sex with Men are present in the slums;
• The slum dwellers have a low socio-economic conditions and lack access to health services;
• The slum dwellers have a low literacy level and lack access to information on HIV.

“Migrant” in the present study defined as “a person who had been more than twelve months outside his/her place of residence in his/her adult years (18–49 years)”.

“Slum” in the present study defined as “a compact area of at least 300 population or about 60-70 households of poorly built congested tenements, in unhygienic environment usually with inadequate infrastructure and lacking in proper sanitary and drinking water facilities.”

Sampling method

The Simple-Random Sampling method was adopted as a sampling method for the present research, in order to allow for comparison between migrant and non-migrant sampled population. Secondary data such as records from the hospitals, government bodies, academic institutions, NGOs and international organizations were used to complete the preliminary data. A total of 1009 households/respondents were selected from five selected slums for the schedule. The selection of the participants to the study was done to ensure that the universe will be adequately represented.

Slum selection (districts/sites and communities in the slum identification)

Identification of district/sites and slum communities was done based on literature review from Governmental, Non-Governmental, International and Academic Institutions on the following basis:
• STI/HIV/AIDS prevalence per district. Samples include respondents coming from highly and lower HIV affected districts (Source: State Public Health Department, local authority, Tamil Nadu AIDS Control Society, International (UNICEF) and local (APAC-VHS) organizations/NGOs);
• Presence of migrants (Source: Census data, local authority, International and local organizations/NGOs);
• Geographical distribution - different geographical environment. (Source: Department of Geography, University of Madras, Tamil Nadu Slum Clearance Board);
• Socio-economic (poorest slums) and housing condition in the Chennai Metropolitan City slums. (Source: Tamil Nadu Slum Clearance Board, local NGOs, academic institutions);
• Diversity of occupational background (Source: preliminary assessment of the slums by the researcher).

The selection of the Districts/sites and particular slums was done based on the methodology explained above. Sampling method for communities in the slum included a detailed analysis of the available information regarding the situation in the slums in Tamil Nadu based on the Tamil Nadu Slum Clearance Board, academic, local and international non-governmental organizations reports and expertise. When the selection of the districts/sites was completed, the researcher selected 15 slums and out of them 5 group slums (located in the same geographical area and with identical socio-economic, health and cultural background). The Geographical distribution of the slums (in the South, North, East, and West, “inside” the center of the city and “outside” sub-urban part of the corporation, in the river bank, and on the sea side).

All efforts were made to cover as much as possible different geographical locations to be representative of the Chennai Corporation (See Chart 12.). In Chennai there are a total of 155 corporation divisions, which are grouping in the 10 zones (TNSCB, 2003). The slums for the study were selected from each zone. A total of five zones and 15 slums were selected. After completing the selection procedure the final selection was made and followed by an ethnographic assessment of the selected slums. The researcher assessed all available information regarding the selected slums. No changes of the selected slums were done after the first selection round.

Sampling in the slum

The method of sampling in the selected slums was a simple-random sampling. The simple- random sample is a probability sampling technique in which each subject in the population has an equal chance of being chosen for the study. This procedure makes the result more likely to be generalized to the entire population. Based on literature review and ethnographic observations of the studied slums, the researcher prepared the map of the each studied slum using PRA method. Maps of selected slums indicate each household location with individual number from 0001 to 1000 in each selected slum. Based on these maps, the researcher selected numbers at random, from the table of random numbers until the desired 200 households per slum were attained.

Data collection

..The question, then, is not whether the two sorts of data [qualitative and quantitative] and associated methods can be linked during study design, but whether it should be done, how it will be done, and for what purposes. (Miles, and Huberman, 1994, p. 41.)

Data collection of the present research was step wise including qualitative and quantitative methods. Each of the seven steps (see diagram) interconnected (they do not follow systematically the order represented in the graph above). In each slum an individual approach was used.

The first step of the data collection was a preliminary profile of the selected slum. It allowed the researcher to be sure that the selected slum suited the study objectives. The preliminary profile also helped the researcher to make PRA map of the studied slum with detailed numbering of the households (see Map 4). The second step included the preparation of the PRA map of the selected slums including household positioning and numbering. The third step was the preparation and the implementation of schedules. The interviews covered approximately 20 per cent of the population in the studied slums. The average selected slum size was 1000 households.

The fourth step was a thematic Focus Group Discussions, where different groups from the slum community were invited including, elderly, women leaders, children etc. The fifth step gave an opportunity to hear the life stories of the people who live in the slum. The sixth step included various qualitative methods which had not been listed previously. These methods are Cognitive methods, Timeline, and Daily Activity Chart. The last seventh step is the concluding step of the data collection. It correlates all available qualitative and quantitative information together with an ethnographic observation of the studied slums.

Quantitative methods

The schedule is the main source of information about the studied population. The schedule includes different aspects of the slum dwellers’ socio-economic condition, labour condition, migratory status, access to health, education and labour. Behavior aspects have focused on the knowledge, attitude and practice of the HIV/AIDS and STI, stigma and discrimination related to HIV/AIDS. Quantitative methods also used qualitative tools (see in qualitative methods chapter). These tools convert qualitative information into quantitative using statistical software SPSS 10.

Schedule

The schedule mainly focused on three aspects: socio-economic situation, HIV/AIDS/STIs and migration. This quantitative method utilized different tools to measure poverty, sexual behavior, migratory habits etc. Concepts and definitions of poverty analysis in this report adopt a monetary measure of living standards, using consumption rather than income. Well-being is measured by expenditures on basic needs for survival: food, clothing, health, shelter and education. The poor are defined as members of society who are unable to afford basic minimum needs. This report defines poverty in ‘absolute’ rather than relative terms, referring to those who cannot meet the universally recommended minimum basic requirements for human survival. Definitions of food poverty, overall and hardcore poverty were not used in this study as no sufficient funding was available for a broader schedule .

A draft schedule was prepared and submitted with the research proposal to The Ethical Committee of Madras University, Chennai, The Tamil Nadu Slum Clearance Board, Chennai, and the Tamil Nadu AIDS Control Society. After having incorporated recommendations from all these institutions, 40 schedules were tested during the first field visit in two different slums selected randomly in Chennai. Other external advisers were informally consulted for the finalization of the schedule, including representatives from UNAIDS, ILO, APAC (VHS), and local NGOs.

The schedule is the main source of information from the studied population. It includes different aspects of the life, behavior, knowledge, attitude and practice of the respondent.

Qualitative methods

Qualitative methods in this study included both Public Health and Anthropological tools, to reach a maximum understanding of the general thinking and behavior of targeted population on health, illness, and migration (taking into account the cost effectiveness and time effectiveness of the research).

The narrative analysis approach helped us to understand the meaning associated with illness/HIV/AIDS (Cortazi, 1993). Participatory assessments with Participatory Rapid Appraisal (PRA) were also used. These techniques included tools such as a semi-structured interviewing/focus group discussions, oral history/case studies, observation, listening surveys, construction of diagrams and maps (mobility maps, social maps, seasonal calendar, time lines, historical profiles, daily routine diagrams, livelihood analysis diagrams and flow diagrams). PRA methods gave an in-depth understanding of the communities within a limited time.

Narrative analysis approach

Narrative analysis approach is a relatively new strategy for medical anthropologists working with cognitive methods. Cognitive methods in this study mainly focused on determining the cultural models of HIV/AIDS that exist in the studied areas. It helped to understand the general thinking and behavior of people regarding health, illness, and migration. It was used for understanding the cultural perception of illnesses of the targeted population. One of the strength of a discourse analysis approach is that it presents the voices of the research participants, which are rarely heard in more traditional research. Consequently research participants have often felt misrepresented in the findings. For this reason, it is proposed to use methods that give more weight to the voices of our research participants to allow the researcher to include cultural perceptions in future recommendations.

Participatory Rapid Assessment (PRA)

Participatory Rapid Assessment (PRA) is a particular form of qualitative research used to gain an in-depth understanding of a community or a situation. It is fully applicable to the present research as it highlights the dynamics within the community. PRA draws on techniques and traditions of applied anthropology. This method provides information about studied communities and more specifically about their status:
• The community status: geography, demography and epidemiology, socio-economic activities and relationships, and health resources.
• The household status: composition, housing, socio-economic activities and status, definitions of health and illness, common illnesses and treatments, foods, diet of sick children, morbidity history, inventory of household remedies, use of health resources, use and experiences with official health resources, and migratory process.

The PRA sessions made use of tools such as semi-structured interviewing/focus group discussions, oral history, observation, listening surveys, construction of diagrams and maps (mobility maps, historical profiles, daily routine diagrams, and livelihood analysis diagrams), depending on their applicability to the local situation. In the present research not all these tools were used in the selected slums. Some were used to complete the available data from the schedule. In the participatory rapid appraisal the following PRA techniques were applied: a/ Social Mapping; b/ Wealth Ranking; c/ Time line.

In each slum the process began with a social mapping exercise followed by wealth ranking, time line and focus groups and individual household visit for personal interviews. The group size composition (male and female) and the process and purpose of each tool are as follow in the tables: 93 Social Mapping, 94 Wealth Ranking, 95 Time line (see Annex 1).

Focus group discussion

Since 1940s sociologists working with the U.S. military developed Focus Group Discussions to assess the effectiveness of propaganda materials intended to boost military morale (Hardon, et al., 1995). Nowadays researchers from different fields extensively use FGDs to evaluate advertising and marketing strategies. Anthropologists use FGDs mainly in applied fields such as intervention research. In this research FGDs supplement or confirm information on community knowledge, beliefs, attitudes and behavior on HIV/AIDS, migration and poverty. FGD participants were recruited by convenience from the studied communities. Based on the nature of this tool it helped explore more information about the studied population in the slums.

Benefits

No fees were given to the participants in any stage of the research. Awareness raising sessions were organized among slum dwellers on HIV/AIDS/STIs after completion of the data collection.

Field test of the methodology

Prior to fieldwork, the researcher met with district authorities to discuss the study objectives and methodology, to collect relevant information, to organize logistics for collection of the data. The researcher also tested 40 schedules and all methodological parameters before the study begun.

Data processing and analysis

Data from the schedule were inputted using SPSS 10 software program. To maximize the accuracy of the information, data were entered twice. Exit tables from the schedule were analyzed with mean, range, standard deviation, chi-square tests, confidence interval, p- value, t-test and other appropriate statistical tools. Group-based participatory methods provided additional elements for analysis of the results.

Statistical analysis

In this study statistical inference was chosen to undergo statistical analysis of the data from the schedules. Statistical inference was chosen because it is branch of statistics which is concerned with using probability concept to deal with uncertainty in decision-making.

Hypothesis testing: Hypothesis testing begins with an assumption, called a hypothesis, which we make about a population parameter. A hypothesis is a supposition made as a basis for reasoning. The first thing in hypothesis testing is to set up a hypothesis about a population parameter. Then we collect sample data produce sample statistics, and use this information to decide how likely it is that our hypothesized population parameter is correct. We assume a value for a population mean. To test the validity of our assumption, we gather sample data and determine the difference between the hypothesized value and the actual value of the sample mean. Then we judge whether the difference is significant. The smaller the difference, the greater the likelihood that our hypothesized value for the mean is correct. The larger the difference, the smaller the likelihood is. The conventional approach to hypothesis testing is not to construct a simple hypothesis about the population parameter, but rather to set up two different hypotheses. These hypotheses must be so constructed that if one hypothesis is rejected, the other is accepted and vice versa.

The null hypothesis is a very useful tool in testing the significance of difference. In its simplest form the hypothesis asserts that there is no real difference in the sample and the population in the particular matter under consideration (hence the word ‘null’ which means invalid, void or amounting to nothing) and that the difference found is accidental and unimportant arising out of fluctuations of sampling. Having set up the hypothesis, the next step is to test the validity of null hypothesis against the alternative at a certain level of significance. The confidence with which an experimenter reject – or accepts – null hypothesis depends upon the significance level adopted. The significance level is customarily expressed as percentage, such as 5 per cent, is the probability of rejecting the null hypothesis if it is true. When the hypothesis in question is accepted at the 5 per cent level, the researcher is running the risk that, in the long run, researcher will be making the wrong decision about 5 per cent of the time. By rejecting the null hypothesis at the same level researcher runs the risk of rejecting a true hypothesis in 5 out of very 100 occasions. By testing at the 1 per cent level researcher seeks to reduce the chance of making a false judgment but some element of risk remains (1 out of 100 occasions) that researcher will make the wrong decision, i.e., researcher may accept where he ought to have rejected or vice versa.

The probability value or p value (also known as significance value) associated with a test is the probability that we obtain the observed value of the test statistic or a value that is more extreme in the direction of the alternative hypothesis calculated when the null hypothesis is true. Rather than select the critical region ahead of time, the p-value of a test can be reported and the reader ultimately makes a decision. If p value is less than 0.05 (or 0.01) then the null hypothesis would be rejected at 5 per cent (or 1 per cent) level of significance and other wise accepted. Hence it can be said that if it is at 5 per cent level it is statistically significant and at 1 per cent level it is highly statistically significant.

Chi–Square test is one of the simplest and most widely used non-parametric tests in statistical work. It is denoted by the symbol and it was first used by Karl Pearson. The quantity chi–Square describes the magnitude of the discrepancy between theory and observation.

The t–test involves taking the difference between the two scores for each respondent and the finding the mean of these difference scores.

Duration of the study

The total duration of the study was 29 months from October 2002 to February 2005. Time frames for each slum were different depending on the accessibility of the community/group such as festivals, raining seasons and work time morning/evening; all quantitative data collection was completed within two months from first of January to first of March 2004 and all qualitative data was collected during two years from December 2002 to December 2004. The researcher carried out field research with assistance of the different NGOs and CBOs, as it was applicable.

Ethical aspects

The research followed the ethical guidelines of the Indian Council of Medical Research (ICMR). Ethical and technical aspects have been discussed with the ICMR, and with the University of Madras appropriate ethical committee. The research proposal was submitted to the Tamil Nadu AIDS Control Society. External experts from various organizations working in the HIV/AIDS field have been consulted on ethical and technical aspects of the research. The field research started after approval of all committees. Properly signed Subject’s Concern form was obligatory for each participant in the study.

The fields of this study are sensitive and may be the subject of academic and political differences. The author carefully checked the results of the research and introduced them with a balanced analysis. To summarize, the present study followed these principles in the research process:
• The study is designed to protect to the maximal extent possible the interest of the participants, and the confidentiality of the data collected;
• Properly signed Subject’s Concern form was obligatory for each participant in the study;
• Schedule and all documentation were not to bear the names of the participants but identification numbers;
• Interviewers were trained to respect the privacy of the participants;
• Interviewers were not to ask the names of the participants;
• A week before the interview, all participants were informed about the study and its methodology;
• The final report of the study will by distributed to relevant local authorities and will be made available to participants.
• Several ministries of the Government of India such as the Ministry of Human Resource Development, the Ministry of Home Affairs and the Ministry of Health and Family Welfare granted/approved research proposal and activities related to the research. Tamil Nadu Slum Clearance Board gave full support to the research project. The Human Ethical Committee (formed and functioned based on regulations of ICMR), Institute of Basic Medical Sciences, University of Madras approved the research proposal.

Envisaged follow-up

Dissemination of research findings will be done through an workshop involving policy makers and practitioners for the set-up of a Tamil Nadu Plan of Action on HIV/AIDS among Migrants. It will be proposed for sponsoring to external donors or depending on available resources. The workshop will involve policy makers such as Tamil Nadu AIDS Control Society, Tamil Nadu Public Health Department and practitioners from local and International NGOs, academic institutions in order to review the practical steps that need to be taken stunning out of the research recommendations for policy level changes and activities. Both research findings and research process/lesson learnt have been uploaded on a continuous basis on a website for easy reference.