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Curtin University
Collaboration for Evidence, Research and Impact in Public Health

Investigating Australian male expatriate and long term traveller social networks in Thailand to determine their potential to influence HIV and other STI risk behaviour (2010-2013)

Investigators:

Chief Investigators

Project Manager/PhD Candidate

Funding and Collaborative Partners

  • Funding has been provided for the research attached to this PhD by the Department of Health (WA) and NT Health. The Western Australian AIDS Council has provided in-kind support for the project.

Background

Recent rate increases in Western Australia (WA) of overseas acquired HIV differ to previous patterns of HIV diagnosis, traditionally acquired through sex between men. Epidemiological data suggests the number of Western Australians acquiring HIV while working or travelling overseas more than doubled from 2004 to 2006 (Combs and Giele 2009). In addition rates of sexually transmitted infections (STIs) remain high (Department of Health Western Australia [DoHWA] 2008). The Australian Bureau of Statistics (ABS) reported that from 2000 to 2006 there was an increase in Australians travelling overseas, particularly to countries of high HIV prevalence such as Thailand (ABS 2007). It has been posited that increases are due primarily to a booming economy and frequent overseas travel related to the resources industry (WAAC 2007). However, early analysis of social research commissioned by the DoHWA indicates a strong expatriate culture and networks existing outside the Australian environment (Brown, 2009). 
           
Many studies have highlighted the links between travel and sex (Hughes and Bellis, 2006; Memish and Osoba 2006; Mercer et al 2007; Mulhall et al. 1993). Much of the available literature comprises UK, US and European research examining sexual risk behaviour whilst travelling including: number of sexual partners, frequency and consistency of condom use, testing and travel advice for STIs and Blood Borne Viruses (BBVs) (Benotsch et al 2006; Bloor etc al 1998; Egan 2001; Hamlyn et al 2007). There is however a dearth of information regarding the local relationships formed by expats and travellers; how individuals enter networks and are socialised into networks, and the effects that these social networks have on their sexual intentions and behaviour. There is also paucity in the literature regarding information shared in relationships between members of social networks and the opportunities to utilise information gleaned from these relationships (Smith et al 2006).

Research has examined Australian heterosexual males who acquired HIV while travelling to high prevalence countries such as Papua New Guinea and Southeast Asian countries including Thailand. These acquisitions have occurred through high risk sexual behaviour with sex workers and bar girls, and amongst expatriate communities (DoHWA 2007; National Centre in HIV Epidemiology and Clinical Research, 2009). Other research has indicated that compared to Australian women, men from Australia who were travelling to Thailand were more likely to pre-plan to engage in casual sex and more likely to choose a Thai partner as a sexual partner (Mulhall  et al. 1993).

Social research commissioned by the Department of Health WA and conducted by Dr Graham Brown (2009) has   investigated overseas acquired HIV amongst Western Australian men. The research was conducted with men who had acquired HIV (not other STIs) and discussed specific behaviour including their recollections of the risk experiences leading to their HIV diagnosis. The research indicated that the significance and role of social networks amongst these men while in country may be very influential, particularly amongst a group that seems aware of the HIV and STI epidemiology and other risk factors of where they are based. This indicates that interventions that engage with and utilise these groups and networks may be effective in targeting programs more effectively, as has been the case with peer based network interventions with gay men, sex workers, people who inject drugs, and young people.

To develop effective peer and social influence interventions, it is critical to have a comprehensive and clear understanding of how these networks and groups operate, interact and sustain themselves, especially within contexts of people who regularly travel.

The effect of increasing travel and internationalisation of work practises has led to new considerations in the protection and enhancement of the health of Australians which warrant further exploration (ABS 2007). Examination of the social networks which exist amongst Australian expatriates in South East Asia (particularly Thailand) may assist to identify influential change agents which could guide interventions, particularly at the peer, network and social influence level that have been successful especially in Australia.

Project Aim and Objectives

To determine whether social network processes of Australian male expatriates1 in Thailand have the potential to support peer education and social influence interventions to reduce transmission of HIV/STIs.

The objectives are:

  • To build a deeper contextual understanding of culture2 and personal behaviour amongst Australian expatriates in Thailand.
  • To describe the socialisation process and pathways experienced by Australians (potential new expatriates) interacting with Australian expatriates in Thailand.
  • To investigate the roles of Australian expatriates as mentors and potential change agents within expatriate social networks in Thailand.
  • To construct a theory explaining the development of social networks amongst Australian expatriates and frequent/longer term travellers, and their capacity to support peer education and social influence interventions to reduce sexual health harms including HIV and other STIs. 
  • To make recommendations for further research and intervention research targeting expatriates and frequent or longer term travellers, including the application of group and social network analysis research.

Project Overview

Internationally recognised for its response to the Human Immunodeficiency Virus (HIV) epidemic, Australia has demonstrated a strong partnership approach, high levels of investment, action by affected communities and utilisation of peer and social influence in prevention strategies (Benard et al. 2008; Commonwealth Department of Health and Ageing 2005). However, a recent change within transmission dynamics in Western Australia (WA) means that these approaches need to be considered in new contexts.

WA epidemiological data suggests an increasing number of diagnoses of HIV amongst men, acquired while working or travelling overseas, including amongst heterosexual men (Department of Health Western Australia [DoH WA] 2009; National Centre in HIV Epidemiology and Clinical Research [NCHECR] 2009). Surveillance has demonstrated that many of these new infections have occurred in South East Asia, particularly within Thailand.  The increases have been linked to a number of factors including strong expatriate culture and networks which exist outside Australia (Brown 2009; Combs and Giele 2009; DoH WA 2009; Western Australian AIDS Council 2008). 

A paucity of information exists regarding local relationships formed by expatriates (expats) and travellers within Thailand; the information shared in relationships between members of social networks and the effects that these relationships have on their sexual intentions and behaviour. Examination of these factors may identify influential change agents to guide interventions, predominantly at the peer, network and social influence level that have been the dominant approach in HIV and have proved successful, particularly within Australia.

Although this research is driven by sexual health priorities, the primary focus is to gain a deeper understanding of the Australian expatriate culture, networks and experiences in Thailand to guide further intervention and research work. The study will use a grounded theory methodology guided by the theoretical perspectives and analytical framework of Symbolic Interaction (SI). Data will be collected through in-depth interviews with participants recruited through purposive sampling amongst long term travellers and Australian expatriates in Australia and Thailand, and other relevant informants. This research will make recommendations for future policy, social network analysis and health promotion interventions and will inform sexual health (and HIV) responses at the state and national level.

Participants

Non probability, purposive and theoretical sampling will be used to access key informants whose information can provide depth, detail and individual meaning about expatriate and longer term travellers and be a source of rich data (Grbich 1999; Patton 2002). The researcher is interested in several types of informants who can provide both personal accounts of living as an expatriate as well as those participants whose professional and volunteer role will assist to seek out expatriate networks, who are familiar with expatriate culture and whose expertise will guide the research.

Key informants for the purposes of this research are defined as “…people who are particularly knowledgeable about the inquiry setting and articulate about their knowledge-people whose insights can provide particularly useful in helping an observer understand what is happening and why” (Patton 2002, 321). Two types of participants will be recruited for this study.

Individuals from Agencies/Organisations
The first will be key informants from agencies and organisations who can provide context for this research and provide contacts for expatriate networks. Western Australian and Thailand based community, government and business organisations will be used to source these key contacts for interviews.  Staff and volunteers at the following agencies will be approached to participate in the interviews to provide expertise and key information for the project as well as gauging their level of support for future research/intervention project. Most have already indicated support to participate in the study. Participants may be any gender but will all be over 18 years of age.

Thailand (one to two initial interviews at each organisation)

  • Australian Embassy
  • Community based and government STI and HIV organisations in Thailand.
  • Organisations working with sex workers/bar girls, men who have sex with men (MSM) and people who inject drugs (PWID) (such as EMPOWER [sex worker organisation]; Rainbow Sky Association of Thailand)
  • Expatriate clubs and associations (such as: Australians in Thailand; Expats' Association of Thailand; Australia Thailand Business Council; Australian-Thai Chamber of Commerce)
  • Australian Thai bar owners
  • Other Bar owner associations

Australia (one to two initial interviews at each organisation)

  • Australian Federation of AIDS Organisations
  • Centre for International Health: Curtin University
  • Australian Research Centre in Sex, Health and Society: La Trobe University
  • WA AIDS Council 
  • WA Department of Health

Male Expatriate and Longer Term Travellers
The selection criteria for the research participants will comprise Australian male expatriates who are or have recently been expatriates in Thailand (see our definition of expatriate on page one of the application). They will be over the age of 18 years. Every endeavour will be made to achieve a diverse sample of expatriates and other informants on the basis of age and culture, with a recognition that Australian expatriates come from a wide range of cultures and backgrounds and were not necessarily born in Australia.

Broadly the research is interested in interviewing men who travel to Thailand for work or for long term holidays, and who consider themselves expatriates or long term travellers. More specifically this will consist of men over the age of 18 and either a current or past expatriate or a long term traveller to Thailand. The sample is expected to consist of approximately 20-30 interviews with a range of men within this criteria including:

  • Expatriates from Australia working in the entertainment industry (bars/clubs etc);
  • Expatriates from Australia working in other contexts, including: professionals, men working in mining/resources, Aid workers etc;
  • Expatriates or longer term travellers from Australia travelling to and from Thailand (in Australia/Thailand) for pleasure; for work; or work and pleasure.

Definitions: An expatriate for the purposes of this research is defined as someone who has taken up a paid work position within an organisation in Thailand for a period of more than six months. A long term traveller is defined as someone who has spent more than six months within a 12 month period in Thailand.

A snowball technique will be used to access men within networks. The research participants will initially be sourced through members of the steering group (outlined below), including key informants who are long term expatriates, or through interviews and discussions with individuals in organisations and agencies in WA and Thailand who can provide key contacts for research participants.

All interview participants will be briefed about the details of the research purpose and methods to ensure informed consent before participation. This is further explained in the ethics section below.

Methodology

Symbolic Interaction (Blumer 1969), will provide the theoretical perspective and analytical framework. Symbolic Interaction studies how humans interact symbolically with their environment, one another and with themselves, and in doing so make decisions about risk, themselves and their action (Charon, 2001).

This qualitative research will use an adapted form of Grounded theory, originally conceived by Glaser and Strauss (1965; 1967) and further developed by Corbin and Strauss (1990). In essence, grounded theory draws understanding and the development of theory about the area under investigation from the data collected, building the theory through a process of constant comparison of themes and concepts as the data is collected and analysed (Strauss and Corbin 1998; 2008).

Data Collection

It is anticipated that this project will incorporate the following stages within the data collection and analysis.

  • Desktop analysis and literature review
  • Steering Group
  • Key informant interviews in Australia and Thailand
  • Interview Schedule
  • Audit of Selected Settings 

Data Analysis

As described above, data for this research will be analysed using the constant comparative approach (Corbin and Strauss 2008; Patton 2002). Constant comparison requires the comparison of interviews and later the data to theory that is generated. This means that data will be collected and analysed simultaneously (Patton 2002).  As described above, Symbolic Interactionism will provide the overall analytic framework. Psychosocial theories which assist in understanding the qualities of communities or settings that support the use of peer education, peer support and social influence will also be assessed for their relevance.

Once data has been collected it will be transcribed into a document compatible for use with PC based word processing. Interviews will be transcribed in a manner that will maintain the confidentiality of the participants. The data will be systematically managed.  Computer–assisted qualitative data analysis software will be used to facilitate the management, storage, coding, retrieval comparison and linkage of data. For the purposes of this research Nvivo will be used.

Key Outcomes (projected and those achieved to date)

An initial scoping visit was undertaken in January 2010 to Thailand (Phuket, Pattaya and Bangkok) by the investigating team which included initial interviews with key stakeholders and informants. Funding has been obtained from NT Health to conduct additional interviews in 2011 in Darwin.

Data Collection Rounds:

Round One    

  • Interviews with key previously identified key informants in Australia (10-15 interviews).
  • Transcribing and analysis of data.

Round Two

  • Interviews with previously and subsequently identified key informants in Thailand (15-20 interviews).
  • Limited analysis and theoretical sampling driven by analysis while in Thailand.
  • Theoretically sampled additional interviews while  in Thailand.
  • Audit of selected settings. Overt participant observation will be conducted in public venues to help develop researcher sensitivity and to provide additional data for potential triangulation.

Round Three

  • Transcription and analysis on return to Australia.
  • Findings discussed with research reference group.
  • Theoretically sampled interviews while in Australia.
  • Follow up telephone or email with previous interviewees.

Round Four

  • Theoretically sampled additional interviews on return trip to  Thailand.
  • Transcription and preliminary analysis.

Round Five

  • Theoretically sampled interviews while in Australia.
  • Potentially follow up telephone or email with previous interviewees.

Round Six

  • Theoretically sampled additional interviews on return trip to  Thailand.
  • Transcription and preliminary analysis.

The following papers are likely to be written during the course of the research:

  • A review of the literature regarding expatriate culture, sexual health and expatriates, social networks and SI.
  • Socialisation process and pathways experienced by Australians (potential new expatriates) interacting with Australian expatriates in Thailand.
  • A description of key findings regarding expatriate culture and personal behaviour including perceptions of risk.
  • An exploration of expatriates as mentors and potential agents of change (may also explore expatriate types).
  • Using Australian expatriate social networks to support peer education and social influence interventions for sexual health.