Accepted Manuscript Beliefs about HIV in low-income Nicaraguan women Rita L. Ailinger, PhD, RN, Lidya Ruth Zamora Cortes, PhD, RN, Suzanne B. Molloy, PhD, ANP PII:
S1055-3290(16)30037-1
DOI:
10.1016/j.jana.2016.04.008
Reference:
JANA 820
To appear in:
Journal of the Association of Nurses in AIDS Care
Received Date: 4 August 2015 Accepted Date: 26 April 2016
Please cite this article as: Ailinger R.L., Zamora Cortes L.R. & Molloy S.B., Beliefs about HIV in lowincome Nicaraguan women, Journal of the Association of Nurses in AIDS Care (2016), doi: 10.1016/ j.jana.2016.04.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Beliefs about HIV in low-income Nicaraguan women
Rita L. Ailinger, PhD, RN
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Lidya Ruth Zamora Cortes, PhD, RN Suzanne B. Molloy, PhD, ANP
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Rita L. Ailinger*, PhD, RN. is Professor Emerita, George Mason University, and Lecturer, University of Massachusetts-Boston, Boston, Massachusetts, USA ([email protected]). Lidya Ruth Zamora Cortes, PhD, RN is Rector of Universidad Politecnica de Nicaragua, Managua, Nicaragua. Suzanne B. Molloy, PhD, RN. is a retired Adjunct Professor, George Mason University, Fairfax, VA, USA. *Corresponding Author: Rita L. Ailinger: [email protected] Disclosures
Acknowledgement
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The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.
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The authors wish to acknowledge the thoughtful review of the manuscript by Kevin Mallinson, PhD, RN, FAAN.
SC
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ACCEPTED MANUSCRIPT
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Abstract
In Latin America, women account for more than 30% of all HIV cases. However, minimal research has been reported on women’s beliefs about HIV in Latin America. The purpose of our qualitative study was to describe HIV beliefs in a sample of low-income Nicaraguan women living in a squatter settlement in Managua. Participants (N = 34) were
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women who participated in 4 focus groups. The mean age of the women was 40 and the mean education level was 5 years. Women reported a plurality of beliefs about HIV, some of which
EP
were biomedically accurate while others were not. Themes of stigma and rejection emerged across all focus group discussions. Younger women were more informed than older women.
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The findings are instructive for nurses working with Nicaraguan women and may be useful in developing HIV education interventions with similar populations in other Latin American countries or with immigrants from those countries.
Key words: beliefs, HIV, Nicaragua
ACCEPTED MANUSCRIPT 2 Beliefs about HIV in low-income Nicaraguan women Nicaragua is a country of more than 6 million people and with a gross domestic product per capita of $5,000; it is one of the poorest countries in Latin America (U.S. Central Intelligence
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Agency, 2015). The incidence of HIV is 30.7 per 100,000, and there has been an increase in the number of people living with HIV (PLWH) in Nicaragua, particularly in the urban areas. In Nicaragua, as elsewhere in Latin America, HIV is expanding, particularly in women. More than
SC
10,000 PLWH live in Nicaragua, and 37% of the cases are adult women. Social conditions are conducive to an epidemic because adolescents start their sexual lives early and a culture of
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machismo encourages multiple partners for men and hidden sexual relationships for homosexual men who may also have female partners (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2015). Soto et al.(2007) reported in a study of five Central American countries that HIV seroprevalence for female sex workers was 0.2% in Nicaragua compared to 9.6% in
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Honduras.
Studies of HIV in Nicaragua are few and not recent. As in other developing countries, HIV is highly under-reported in Nicaragua and the system of testing and reporting is not
EP
reflective of true rates of infection. The infection rate in women was highest in the 20-to 24 year old age group and there were 3 cases of male infection to every 1 in women. A study of
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HIV in adolescents in Leon, Nicaragua, indicated that some of their attitudes were related to machismo and the stigma associated with HIV (Manji, Pena, & Dubrow, 2007). The authors reported that the adolescents had some correct knowledge and some misconceptions, such as HIV transmission by mosquitos or sharing tableware. In terms of attitudes, most of the students disapproved of homosexual behavior and more than half would not share food with a person who had HIV.
ACCEPTED MANUSCRIPT 3 McKay, Campbell, and Gorter, (2006) reported on an analysis of a Managua, Nicaragua HIV prevention program for sex workers. They found that the frequency of treatment for sexually transmitted infections was instrumental in reducing the prevalence of the disease. In a
RI PT
mixed methods study of HIV knowledge in nursing students (N = 290) in Nicaragua, Molloy (2009) reported large gaps in basic HIV knowledge in the areas of prevention, transmission, testing, treatment, universal precautions, and conditions specific to Nicaragua. In addition to the
SC
survey on knowledge, Molloy (2009) also found themes of frustration, fear, sadness,
perceptions collected as qualitative data.
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hopelessness and moving forward to a better future, which emerged from the nursing students’
Few research studies have described HIV epidemiology in Central America. It was noted by Wheeler et al. (2001) that most PLWH in Central America have minimal access to health care services related to HIV. It has been estimated that only 30% of PLWH in Nicaragua who need In the recent literature, only three studies
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antiretroviral therapy receive it (UNAIDS, 2015).
were found that related to HIV in Latin America. Arrivillaga et al. (2012) found that women with higher socioeconomic status in Colombia were more apt to hide an HIV diagnosis due to
EP
fear of stigma. In a study of youth in Cali, Colombia, Giron, Palacio, and Mateus (2013) noted a high incidence of HIV risk behaviors associated with beliefs and socio-demographic factors. In
AC C
a systematic review of factors related to child sexual abuse in Latin America, Thornton and Veenema (2015) found that “victimization was associated with lifelong risk factors for HIV" (p.432).
HIV has disproportionally affected women in various parts of the world including
Latinas. Differences in gender roles between Latino women and men have influenced HIV infection rates (Albarracin & Plambeck, 2010). In a Canadian study, HIV risk perceptions in
ACCEPTED MANUSCRIPT 4 Latin American women immigrants were influenced by their life trajectories (Ochoa & Sampalis, 2014). In order to teach women the information they need to protect themselves, it is important
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to first assess what they understand about the disease, and identify their beliefs about HIV. The purpose of our qualitative study was to describe beliefs about HIV in a sample of low-income Nicaraguan women living in a squatter settlement in Managua.
SC
The community where the study was conducted was an impoverished former squatter settlement. It had more than 15,000 inhabitants and was located in south-east Managua, the
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capitol of Nicaragua. The community was established more than 20 years ago, mostly by single mothers, who had fled war, hurricanes, and earthquakes. During the previous 10 years, the city of Managua deeded the land to many occupants. Houses in the community were approximately 80 square feet and constructed of concrete blocks, cardboard, scrap wood, and tin. About 5 years
TE D
ago, potable water became available for a few hours a day. For more than 18 years, the Polytechnic University of Nicaragua (UPOLI) School of Nursing selected this site for students’ community health practica, using the extreme poverty and poor sanitary conditions as the main
EP
criteria. The authors were very familiar with the community from their work in the community
AC C
with students and previous ethnographic experiences. Methods
Design and Sample
Our study received human protection approval from the George Mason University
Institutional Review Board. In house-to-house visits, women were invited to participate in the study at the Academic Nursing Center by the researchers and the leader of volunteer health promoters in the community. The nursing faculty of UPOLI run the Academic Nursing Center,
ACCEPTED MANUSCRIPT 5 providing health education, cancer prevention, men’s health, mental health programs and domestic violence prevention. Volunteer health promoters have been trained in sanitary education by the UPOLI faculty.
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Informed consent was obtained with a document, written at the 6th grade reading level in Spanish which included the purpose of the study and the assurance of confidentiality and anonymity. Inclusion criteria were women living in the community who were willing to
SC
participate in the study. There were no exclusion criteria. The women were informed that the study was being conducted to learn about their beliefs about HIV. They received $1 USD at the
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end of the focus group session in appreciation for their time. U.S. currency was used because of the value people in the country put on American money due to its stability. Women in the community make an average of $3.50 USD per day.
Four groups of women came to the Academic Nursing Center in the community on
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different days to participate in the focus groups. The investigators, who had experience conducting focus groups with women, believed that the women who came to the center were not only interested in sharing their beliefs, but also in associating with other women in the
EP
community. Three of the groups included mostly middle-age women and one group had four younger women. The community leader and head health promoter thought that the younger
AC C
women were probably working or in school, and may not have wanted to be in a group with their older female relatives. The women in the study (N = 34) had a mean age of 49 (SD = 15, range = 18 - 67). They had an average of four children (SD = 3, range = 0 - 13). Most of the women (74%) were homemakers; 15% were engaged as domestic workers, 5.5% were college students, and 5.5% were independent vendors. In terms of marital status 41% were single, 38% were married and 11% were living with partners or were widowed.
ACCEPTED MANUSCRIPT 6 Measures The authors, fluent in Spanish, conducted the focus groups using questions adapted from part of the AIDS Rapid Anthropological Assessment Procedure (AIDS RAP; Scrimshaw,
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Carballo, Ramos, & Blair, 1991). AIDS RAP is a group of guidelines that can be used to gather data on a community’s attitudes and beliefs about HIV. From the guidelines, 13 open-ended questions (see Table 1) were developed and asked in each of the focus groups. The questions
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focused on beliefs and attitudes about HIV in the context of the community in which the women lived. For example, What is the difference between HIV and AIDS?, How do people react to
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someone with AIDS?, Where do people go for treatment?, and What home remedies do people use for HIV?. The focus groups were audiotaped and transcribed in Spanish by a native Nicaraguan with experience in transcription. Analytic Strategy
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Demographic data were analyzed and frequencies and descriptive statistics were obtained. Transcriptions of the qualitative data were reviewed for accuracy. The first two authors immersed themselves in the data by reading each transcription, in Spanish, several times
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at the start of data analysis and used latent content analysis to arrive at codes independently. The two researchers then reviewed the coding together, resolved differences, and arrived at
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consensus. At this point in the analysis, the codes were translated into English. Codes were then grouped to identify emerging themes. Results
All participants knew that unprotected sexual intercourse was a cause of HIV and that
using condoms would protect them. They also reported that other causes were infected syringes and transfusions. When asked, How do you know if someone has HIV? all of the participants
ACCEPTED MANUSCRIPT 7 agreed that they wouldn’t know. One participant offered the comment “You don’t know because they act normally. The only way to tell is by medical exams.” The women reported the symptoms of HIV as diarrhea, fever, and skin problems. They
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also noted that PLWH lack defenses. When asked to describe the progression of HIV to AIDS, respondents used phrases such as “it eats like cancer,” “it progresses silently, little by little.” Because home remedies were commonly used for a variety of health problems in Nicaragua, the
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women were asked if they knew of any remedies for HIV. None of the women reported
knowing of any home remedies for HIV. They all agreed that the place for treatment was the
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local public health clinic. The younger women were more informed than the older women. Several themes emerged from the qualitative data. Ambiguity was the theme that prevailed when the women were asked whether HIV existed in the community or whether any deaths had occurred due to HIV infection. Some of the women said they didn’t know if there
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were any cases in the community “that we know of, no.” Others said that there were cases, “I know that one person died here of AIDS”; others said there were no cases. “We don’t know if anyone has AIDS in the community because people who have it keep it a secret”. This was the
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response of one of the women in the focus group when asked if HIV existed in the neighborhood. There was a lack of transparency about HIV. In Nicaragua HIV is not talked about openly and,
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although the number of cases has increased in recent years (UNAIDS, 2015), there was still much denial that it was a problem. Fidelity to one’s partner was the theme that described the most common response to
ways of protecting oneself from HIV, and infidelity was mentioned as the cause of HIV. For example, one participant said, “The lack of communication in the couple and the man won’t say he was out with another woman.”
ACCEPTED MANUSCRIPT 8 Informants said that people’s reactions to knowing that someone had HIV was discrimination and stigma. Other themes identified were fear, rejection, and sadness in people’s reactions to PLWH. One woman said, “The reaction is primarily one of sadness and then the
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person is rejected, and people say the person has no value, this makes for more sadness.”
Participants said that PLWH were discriminated against and people would stay away from them because they were afraid of contagion, “Es cierto” (for sure) . “They won’t touch the person and
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were afraid of the person with HIV,” and “If they think a person has died of AIDS they won’t go to the wake or open the casket.”
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The need for more HIV education, both at home and in school, was also emphasized during the focus groups. One woman shared that she tells her male children to “use condoms each time they are misbehaving like pigs.” Another said she tells her daughters to “ask for an AIDS certificate (blood test) when they get married.” The women indicated that they would like
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more talks (charlas) about the problem. They felt that there was so much to learn, and continued meetings with talks would give them the opportunity to learn more about HIV. There was consensus that there was power in their association as a group of women who were leading
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households, and teaching their families, especially the children.
Discussion
Our study findings highlight the plurality of concepts about HIV in the low-income
women in this Nicaraguan urban community, which was similar to the findings in the study of adolescents in Nicaragua (Manji et al., 2007). Participants in the focus groups frequently mentioned fidelity and infidelity, when talking about HIV. This was also found in the study of Colombian women (Arrivillaga et al., 2012). Discrimination and rejection by others due to the
ACCEPTED MANUSCRIPT 9 stigma of HIV were themes that evolved from the focus groups. Stigma was also reported by Arrivillaga et al. (2012). The women in our study were fairly knowledgeable about HIV, unlike the sample in Molloy’s (2009) study where there were large gaps in basic HIV knowledge. This
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may be due to public education campaigns and the health education programs that UPOLI nursing faculty and students provide through the Academic Nursing Center.
One of the limitations of the study was the predominance of middle-age women in the
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sample. Future research should focus on HIV prevention through education, especially
education about the themes of discrimination, secrecy, and infidelity identified in our study.
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Further studies on the HIV perspectives of younger women and men in Latin America would be helpful to nurses and other clinicians delivering health care there and with immigrants from those countries.
Conclusions
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By knowing about the concepts held by these women, nurses can adjust communications with women to include an exploration of these concepts in health teaching and counseling. For example, women frequently mentioned the stigma of HIV and this topic could be opened in talks
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to the public as well as with PLWH. Supportive and compassionate care could also be discussed. The women were clearly informed about ways to protect themselves from HIV (men
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using condoms) and the places to get treatment as well as how to tell if one has the disease by medical exam. However, their fears of touching a person with HIV and of going to the wake of a person who died of HIV also demonstrated the misconceptions that they held. These need to be addressed in future health education programs.
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References Albarracin, J., & Plambeck, C.R. (2010). Demographic factors and sexist beliefs as predictors of
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of condom use among Latinos in the USA. AIDS Care, 22(8), 1021-1028. doi:10.1080/09540121.2010.487089
Arrivillaga, M., Springer, A., Lopera, M., Correa, D., Useche, B., & Ross, M. (2012).
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HIV/AIDS treatment adherence in economically better off women in Colombia. AIDS Care, 24(7), 929-935. doi:10.1080/09540121.2011.647678
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Giron, S., Palacio, H., & Mateus, J. (2013). HIV sexual risk behaviors in youth 15-24 years of age in Cali, Colombia: Do differences exist among neighborhoods? Colombia Medica, 2, 72-79.
Joint United Nations Programme on HIV/AIDS. (2015). Nicaraguan narrative report, 2014. Retrieved from
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http://www.unaids.org/sites/default/files/country/documents/NIC_narrative_report_2015. pdf Manji, A., Pena, R., & Dubrow, R. (2007). Sex, condoms, gender roles, and HIV transmission
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knowledge among adolescents in Leon, Nicaragua: Implications for HIV prevention.
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AIDS Care, 19(8), 989-995. doi:10.1080/09540120701244935 McKay, J., Campbell, D., & Gorter, A. C. (2006). Lessons for management of sexually transmitted infection treatment programs as part of HIV/AIDS prevention strategies.
American Journal of Public Health, 96(10), 1760-1761.
Molloy, S.B. (2009). HIV/AIDS knowledge in Nicaraguan students of nursing. Unpublished doctoral dissertation, George Mason University, Fairfax, Virginia.
ACCEPTED MANUSCRIPT 11 Ochoa, S.C. & Sampalis J. (2014). Risk perception and vulnerability to STIs and HIV/AIDS among immigrant Latin-American women in Canada. Culture, Health & Sexuality, 16(4), 412-425. doi:10.1080/13691058.2014.884632
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Scrimshaw, S. C. M., Carballo, M., Ramos, L., & Blair, B.A. (1991). The AIDS rapid
anthropological assessment procedures: A tool for health education planning and
doi:10.1177/109019819101800111
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evaluation. Health Education Quarterly, Spring, 111-123.
Soto, R. J., Ghee, A. E., Nunez, C. A., Mayorga, R., Tapia, K. A., Astete, S. G., … Holmes, K.K.
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(2007). Sentinel surveillance of sexually transmitted infections/HIV and risk behaviors in vulnerable populations in 5 Central American countries. Journal of Acquired Immune Deficiency Syndromes, 46(1), 101-111. doi:10.1097/QAI.0b013e318141f913 Thornton, C., & Veenema, T. (2015). Children seeking refuge: A review of the escalating
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humanitarian crisis of child sexual abuse and HIV/AIDS in Latin America. Journal of the Association of Nurses in AIDS Care, 26(4), 432-442. doi:10.1016/j.jana.2015.01.002 U.S. Central Intelligence Agency. (2015), World fact book-Nicaragua. Retrieved from
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https://www.cia.gov/library/publications/resources/the-world-factbook/geos/nu.html Wheeler, D. A., Arathoon, E. G., Pitts, M., Cedillos, R. A., Bu, T. E., Porras, G. D., … Sosa N.R.
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(2001). Availability of HIV care in Central America. Journal of the American Medical
Association, 286 (7), 853-860.
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Key Considerations Stigma continues to be attached to HIV, especially among Latina women.
•
Public health nurses need to eradicate misconceptions about HIV contact in community
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•
members. •
Nurses should continue to educate Latina women about the priority of insistence on
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More research on beliefs about HIV in other ethnic groups is needed.
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•
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partners using condoms.
ACCEPTED MANUSCRIPT 13 Table 1. Questions about HIV Asked in Focus Groups
2. What is the difference between HIV and AIDS? 3. How does AIDS develop? What is the cause of AIDS? 4. How do you know if someone has AIDS?
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5. How does AIDS progress?
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1. Does HIV and AIDS exist in this community?
children?
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6. What are the symptoms of AIDS? Are the symptoms different in women, men and
7. How do people react to a person who has AIDS? 8. What is the result of AIDS?
9. Where do people go for treatment of HIV and AIDS?
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10. Do people use home remedies to treat HIV and AIDS?
11. Have there been any deaths due to AIDS in this community? 12. How did people respond to these deaths?
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AIDS?
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13. Do the people of the community know how to protect themselves and their families from
S1055-3290(16)30037-1
DOI:
10.1016/j.jana.2016.04.008
Reference:
JANA 820
To appear in:
Journal of the Association of Nurses in AIDS Care
Received Date: 4 August 2015 Accepted Date: 26 April 2016
Please cite this article as: Ailinger R.L., Zamora Cortes L.R. & Molloy S.B., Beliefs about HIV in lowincome Nicaraguan women, Journal of the Association of Nurses in AIDS Care (2016), doi: 10.1016/ j.jana.2016.04.008. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
Beliefs about HIV in low-income Nicaraguan women
Rita L. Ailinger, PhD, RN
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Lidya Ruth Zamora Cortes, PhD, RN Suzanne B. Molloy, PhD, ANP
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Rita L. Ailinger*, PhD, RN. is Professor Emerita, George Mason University, and Lecturer, University of Massachusetts-Boston, Boston, Massachusetts, USA ([email protected]). Lidya Ruth Zamora Cortes, PhD, RN is Rector of Universidad Politecnica de Nicaragua, Managua, Nicaragua. Suzanne B. Molloy, PhD, RN. is a retired Adjunct Professor, George Mason University, Fairfax, VA, USA. *Corresponding Author: Rita L. Ailinger: [email protected] Disclosures
Acknowledgement
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The authors report no real or perceived vested interests that relate to this article that could be construed as a conflict of interest.
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The authors wish to acknowledge the thoughtful review of the manuscript by Kevin Mallinson, PhD, RN, FAAN.
SC
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ACCEPTED MANUSCRIPT
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Abstract
In Latin America, women account for more than 30% of all HIV cases. However, minimal research has been reported on women’s beliefs about HIV in Latin America. The purpose of our qualitative study was to describe HIV beliefs in a sample of low-income Nicaraguan women living in a squatter settlement in Managua. Participants (N = 34) were
TE D
women who participated in 4 focus groups. The mean age of the women was 40 and the mean education level was 5 years. Women reported a plurality of beliefs about HIV, some of which
EP
were biomedically accurate while others were not. Themes of stigma and rejection emerged across all focus group discussions. Younger women were more informed than older women.
AC C
The findings are instructive for nurses working with Nicaraguan women and may be useful in developing HIV education interventions with similar populations in other Latin American countries or with immigrants from those countries.
Key words: beliefs, HIV, Nicaragua
ACCEPTED MANUSCRIPT 2 Beliefs about HIV in low-income Nicaraguan women Nicaragua is a country of more than 6 million people and with a gross domestic product per capita of $5,000; it is one of the poorest countries in Latin America (U.S. Central Intelligence
RI PT
Agency, 2015). The incidence of HIV is 30.7 per 100,000, and there has been an increase in the number of people living with HIV (PLWH) in Nicaragua, particularly in the urban areas. In Nicaragua, as elsewhere in Latin America, HIV is expanding, particularly in women. More than
SC
10,000 PLWH live in Nicaragua, and 37% of the cases are adult women. Social conditions are conducive to an epidemic because adolescents start their sexual lives early and a culture of
M AN U
machismo encourages multiple partners for men and hidden sexual relationships for homosexual men who may also have female partners (Joint United Nations Programme on HIV/AIDS [UNAIDS], 2015). Soto et al.(2007) reported in a study of five Central American countries that HIV seroprevalence for female sex workers was 0.2% in Nicaragua compared to 9.6% in
TE D
Honduras.
Studies of HIV in Nicaragua are few and not recent. As in other developing countries, HIV is highly under-reported in Nicaragua and the system of testing and reporting is not
EP
reflective of true rates of infection. The infection rate in women was highest in the 20-to 24 year old age group and there were 3 cases of male infection to every 1 in women. A study of
AC C
HIV in adolescents in Leon, Nicaragua, indicated that some of their attitudes were related to machismo and the stigma associated with HIV (Manji, Pena, & Dubrow, 2007). The authors reported that the adolescents had some correct knowledge and some misconceptions, such as HIV transmission by mosquitos or sharing tableware. In terms of attitudes, most of the students disapproved of homosexual behavior and more than half would not share food with a person who had HIV.
ACCEPTED MANUSCRIPT 3 McKay, Campbell, and Gorter, (2006) reported on an analysis of a Managua, Nicaragua HIV prevention program for sex workers. They found that the frequency of treatment for sexually transmitted infections was instrumental in reducing the prevalence of the disease. In a
RI PT
mixed methods study of HIV knowledge in nursing students (N = 290) in Nicaragua, Molloy (2009) reported large gaps in basic HIV knowledge in the areas of prevention, transmission, testing, treatment, universal precautions, and conditions specific to Nicaragua. In addition to the
SC
survey on knowledge, Molloy (2009) also found themes of frustration, fear, sadness,
perceptions collected as qualitative data.
M AN U
hopelessness and moving forward to a better future, which emerged from the nursing students’
Few research studies have described HIV epidemiology in Central America. It was noted by Wheeler et al. (2001) that most PLWH in Central America have minimal access to health care services related to HIV. It has been estimated that only 30% of PLWH in Nicaragua who need In the recent literature, only three studies
TE D
antiretroviral therapy receive it (UNAIDS, 2015).
were found that related to HIV in Latin America. Arrivillaga et al. (2012) found that women with higher socioeconomic status in Colombia were more apt to hide an HIV diagnosis due to
EP
fear of stigma. In a study of youth in Cali, Colombia, Giron, Palacio, and Mateus (2013) noted a high incidence of HIV risk behaviors associated with beliefs and socio-demographic factors. In
AC C
a systematic review of factors related to child sexual abuse in Latin America, Thornton and Veenema (2015) found that “victimization was associated with lifelong risk factors for HIV" (p.432).
HIV has disproportionally affected women in various parts of the world including
Latinas. Differences in gender roles between Latino women and men have influenced HIV infection rates (Albarracin & Plambeck, 2010). In a Canadian study, HIV risk perceptions in
ACCEPTED MANUSCRIPT 4 Latin American women immigrants were influenced by their life trajectories (Ochoa & Sampalis, 2014). In order to teach women the information they need to protect themselves, it is important
RI PT
to first assess what they understand about the disease, and identify their beliefs about HIV. The purpose of our qualitative study was to describe beliefs about HIV in a sample of low-income Nicaraguan women living in a squatter settlement in Managua.
SC
The community where the study was conducted was an impoverished former squatter settlement. It had more than 15,000 inhabitants and was located in south-east Managua, the
M AN U
capitol of Nicaragua. The community was established more than 20 years ago, mostly by single mothers, who had fled war, hurricanes, and earthquakes. During the previous 10 years, the city of Managua deeded the land to many occupants. Houses in the community were approximately 80 square feet and constructed of concrete blocks, cardboard, scrap wood, and tin. About 5 years
TE D
ago, potable water became available for a few hours a day. For more than 18 years, the Polytechnic University of Nicaragua (UPOLI) School of Nursing selected this site for students’ community health practica, using the extreme poverty and poor sanitary conditions as the main
EP
criteria. The authors were very familiar with the community from their work in the community
AC C
with students and previous ethnographic experiences. Methods
Design and Sample
Our study received human protection approval from the George Mason University
Institutional Review Board. In house-to-house visits, women were invited to participate in the study at the Academic Nursing Center by the researchers and the leader of volunteer health promoters in the community. The nursing faculty of UPOLI run the Academic Nursing Center,
ACCEPTED MANUSCRIPT 5 providing health education, cancer prevention, men’s health, mental health programs and domestic violence prevention. Volunteer health promoters have been trained in sanitary education by the UPOLI faculty.
RI PT
Informed consent was obtained with a document, written at the 6th grade reading level in Spanish which included the purpose of the study and the assurance of confidentiality and anonymity. Inclusion criteria were women living in the community who were willing to
SC
participate in the study. There were no exclusion criteria. The women were informed that the study was being conducted to learn about their beliefs about HIV. They received $1 USD at the
M AN U
end of the focus group session in appreciation for their time. U.S. currency was used because of the value people in the country put on American money due to its stability. Women in the community make an average of $3.50 USD per day.
Four groups of women came to the Academic Nursing Center in the community on
TE D
different days to participate in the focus groups. The investigators, who had experience conducting focus groups with women, believed that the women who came to the center were not only interested in sharing their beliefs, but also in associating with other women in the
EP
community. Three of the groups included mostly middle-age women and one group had four younger women. The community leader and head health promoter thought that the younger
AC C
women were probably working or in school, and may not have wanted to be in a group with their older female relatives. The women in the study (N = 34) had a mean age of 49 (SD = 15, range = 18 - 67). They had an average of four children (SD = 3, range = 0 - 13). Most of the women (74%) were homemakers; 15% were engaged as domestic workers, 5.5% were college students, and 5.5% were independent vendors. In terms of marital status 41% were single, 38% were married and 11% were living with partners or were widowed.
ACCEPTED MANUSCRIPT 6 Measures The authors, fluent in Spanish, conducted the focus groups using questions adapted from part of the AIDS Rapid Anthropological Assessment Procedure (AIDS RAP; Scrimshaw,
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Carballo, Ramos, & Blair, 1991). AIDS RAP is a group of guidelines that can be used to gather data on a community’s attitudes and beliefs about HIV. From the guidelines, 13 open-ended questions (see Table 1) were developed and asked in each of the focus groups. The questions
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focused on beliefs and attitudes about HIV in the context of the community in which the women lived. For example, What is the difference between HIV and AIDS?, How do people react to
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someone with AIDS?, Where do people go for treatment?, and What home remedies do people use for HIV?. The focus groups were audiotaped and transcribed in Spanish by a native Nicaraguan with experience in transcription. Analytic Strategy
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Demographic data were analyzed and frequencies and descriptive statistics were obtained. Transcriptions of the qualitative data were reviewed for accuracy. The first two authors immersed themselves in the data by reading each transcription, in Spanish, several times
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at the start of data analysis and used latent content analysis to arrive at codes independently. The two researchers then reviewed the coding together, resolved differences, and arrived at
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consensus. At this point in the analysis, the codes were translated into English. Codes were then grouped to identify emerging themes. Results
All participants knew that unprotected sexual intercourse was a cause of HIV and that
using condoms would protect them. They also reported that other causes were infected syringes and transfusions. When asked, How do you know if someone has HIV? all of the participants
ACCEPTED MANUSCRIPT 7 agreed that they wouldn’t know. One participant offered the comment “You don’t know because they act normally. The only way to tell is by medical exams.” The women reported the symptoms of HIV as diarrhea, fever, and skin problems. They
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also noted that PLWH lack defenses. When asked to describe the progression of HIV to AIDS, respondents used phrases such as “it eats like cancer,” “it progresses silently, little by little.” Because home remedies were commonly used for a variety of health problems in Nicaragua, the
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women were asked if they knew of any remedies for HIV. None of the women reported
knowing of any home remedies for HIV. They all agreed that the place for treatment was the
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local public health clinic. The younger women were more informed than the older women. Several themes emerged from the qualitative data. Ambiguity was the theme that prevailed when the women were asked whether HIV existed in the community or whether any deaths had occurred due to HIV infection. Some of the women said they didn’t know if there
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were any cases in the community “that we know of, no.” Others said that there were cases, “I know that one person died here of AIDS”; others said there were no cases. “We don’t know if anyone has AIDS in the community because people who have it keep it a secret”. This was the
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response of one of the women in the focus group when asked if HIV existed in the neighborhood. There was a lack of transparency about HIV. In Nicaragua HIV is not talked about openly and,
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although the number of cases has increased in recent years (UNAIDS, 2015), there was still much denial that it was a problem. Fidelity to one’s partner was the theme that described the most common response to
ways of protecting oneself from HIV, and infidelity was mentioned as the cause of HIV. For example, one participant said, “The lack of communication in the couple and the man won’t say he was out with another woman.”
ACCEPTED MANUSCRIPT 8 Informants said that people’s reactions to knowing that someone had HIV was discrimination and stigma. Other themes identified were fear, rejection, and sadness in people’s reactions to PLWH. One woman said, “The reaction is primarily one of sadness and then the
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person is rejected, and people say the person has no value, this makes for more sadness.”
Participants said that PLWH were discriminated against and people would stay away from them because they were afraid of contagion, “Es cierto” (for sure) . “They won’t touch the person and
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were afraid of the person with HIV,” and “If they think a person has died of AIDS they won’t go to the wake or open the casket.”
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The need for more HIV education, both at home and in school, was also emphasized during the focus groups. One woman shared that she tells her male children to “use condoms each time they are misbehaving like pigs.” Another said she tells her daughters to “ask for an AIDS certificate (blood test) when they get married.” The women indicated that they would like
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more talks (charlas) about the problem. They felt that there was so much to learn, and continued meetings with talks would give them the opportunity to learn more about HIV. There was consensus that there was power in their association as a group of women who were leading
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households, and teaching their families, especially the children.
Discussion
Our study findings highlight the plurality of concepts about HIV in the low-income
women in this Nicaraguan urban community, which was similar to the findings in the study of adolescents in Nicaragua (Manji et al., 2007). Participants in the focus groups frequently mentioned fidelity and infidelity, when talking about HIV. This was also found in the study of Colombian women (Arrivillaga et al., 2012). Discrimination and rejection by others due to the
ACCEPTED MANUSCRIPT 9 stigma of HIV were themes that evolved from the focus groups. Stigma was also reported by Arrivillaga et al. (2012). The women in our study were fairly knowledgeable about HIV, unlike the sample in Molloy’s (2009) study where there were large gaps in basic HIV knowledge. This
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may be due to public education campaigns and the health education programs that UPOLI nursing faculty and students provide through the Academic Nursing Center.
One of the limitations of the study was the predominance of middle-age women in the
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sample. Future research should focus on HIV prevention through education, especially
education about the themes of discrimination, secrecy, and infidelity identified in our study.
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Further studies on the HIV perspectives of younger women and men in Latin America would be helpful to nurses and other clinicians delivering health care there and with immigrants from those countries.
Conclusions
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By knowing about the concepts held by these women, nurses can adjust communications with women to include an exploration of these concepts in health teaching and counseling. For example, women frequently mentioned the stigma of HIV and this topic could be opened in talks
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to the public as well as with PLWH. Supportive and compassionate care could also be discussed. The women were clearly informed about ways to protect themselves from HIV (men
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using condoms) and the places to get treatment as well as how to tell if one has the disease by medical exam. However, their fears of touching a person with HIV and of going to the wake of a person who died of HIV also demonstrated the misconceptions that they held. These need to be addressed in future health education programs.
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References Albarracin, J., & Plambeck, C.R. (2010). Demographic factors and sexist beliefs as predictors of
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of condom use among Latinos in the USA. AIDS Care, 22(8), 1021-1028. doi:10.1080/09540121.2010.487089
Arrivillaga, M., Springer, A., Lopera, M., Correa, D., Useche, B., & Ross, M. (2012).
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HIV/AIDS treatment adherence in economically better off women in Colombia. AIDS Care, 24(7), 929-935. doi:10.1080/09540121.2011.647678
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Giron, S., Palacio, H., & Mateus, J. (2013). HIV sexual risk behaviors in youth 15-24 years of age in Cali, Colombia: Do differences exist among neighborhoods? Colombia Medica, 2, 72-79.
Joint United Nations Programme on HIV/AIDS. (2015). Nicaraguan narrative report, 2014. Retrieved from
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http://www.unaids.org/sites/default/files/country/documents/NIC_narrative_report_2015. pdf Manji, A., Pena, R., & Dubrow, R. (2007). Sex, condoms, gender roles, and HIV transmission
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knowledge among adolescents in Leon, Nicaragua: Implications for HIV prevention.
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AIDS Care, 19(8), 989-995. doi:10.1080/09540120701244935 McKay, J., Campbell, D., & Gorter, A. C. (2006). Lessons for management of sexually transmitted infection treatment programs as part of HIV/AIDS prevention strategies.
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Molloy, S.B. (2009). HIV/AIDS knowledge in Nicaraguan students of nursing. Unpublished doctoral dissertation, George Mason University, Fairfax, Virginia.
ACCEPTED MANUSCRIPT 11 Ochoa, S.C. & Sampalis J. (2014). Risk perception and vulnerability to STIs and HIV/AIDS among immigrant Latin-American women in Canada. Culture, Health & Sexuality, 16(4), 412-425. doi:10.1080/13691058.2014.884632
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(2007). Sentinel surveillance of sexually transmitted infections/HIV and risk behaviors in vulnerable populations in 5 Central American countries. Journal of Acquired Immune Deficiency Syndromes, 46(1), 101-111. doi:10.1097/QAI.0b013e318141f913 Thornton, C., & Veenema, T. (2015). Children seeking refuge: A review of the escalating
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humanitarian crisis of child sexual abuse and HIV/AIDS in Latin America. Journal of the Association of Nurses in AIDS Care, 26(4), 432-442. doi:10.1016/j.jana.2015.01.002 U.S. Central Intelligence Agency. (2015), World fact book-Nicaragua. Retrieved from
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https://www.cia.gov/library/publications/resources/the-world-factbook/geos/nu.html Wheeler, D. A., Arathoon, E. G., Pitts, M., Cedillos, R. A., Bu, T. E., Porras, G. D., … Sosa N.R.
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(2001). Availability of HIV care in Central America. Journal of the American Medical
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Key Considerations Stigma continues to be attached to HIV, especially among Latina women.
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Public health nurses need to eradicate misconceptions about HIV contact in community
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members. •
Nurses should continue to educate Latina women about the priority of insistence on
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More research on beliefs about HIV in other ethnic groups is needed.
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•
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partners using condoms.
ACCEPTED MANUSCRIPT 13 Table 1. Questions about HIV Asked in Focus Groups
2. What is the difference between HIV and AIDS? 3. How does AIDS develop? What is the cause of AIDS? 4. How do you know if someone has AIDS?
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5. How does AIDS progress?
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1. Does HIV and AIDS exist in this community?
children?
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6. What are the symptoms of AIDS? Are the symptoms different in women, men and
7. How do people react to a person who has AIDS? 8. What is the result of AIDS?
9. Where do people go for treatment of HIV and AIDS?
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10. Do people use home remedies to treat HIV and AIDS?
11. Have there been any deaths due to AIDS in this community? 12. How did people respond to these deaths?
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AIDS?
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13. Do the people of the community know how to protect themselves and their families from
