Social Representations of health care professionals on Acquired Immune Defi ciency Syndrome

Objective: To apprehend social representation of health care professionals on HIV/AIDS and to compare it with a subgroup of physicians. Method: Qualitative research based on the Theory of Social Representations. Free associations for the term HIV/AIDS were collected from 73 workers of public services specialized in HIV/AIDS, in Salvador-Bahia. The results were analyzed in the EVOC software. Results: For all health professionals, HIV/AIDS is associated with “prejudice, care, disease and prevention”, and for the subgroup of physicians it is associated with the term “prevention”. Health professionals represented HIV/AIDS similarly to society in general and, due to their normative character, prescribed attitudes typical of health care professionals. Final considerations: The fi ndings show that, despite the advances in the health area regarding the treatment of AIDS, prejudice still persists. It is important to strengthen interdisciplinary actions focused on discussions on this theme during training, favoring the comprehensiveness of the assistance. Descriptors: Assistance; Acquired Immune Defi ciency Syndrome; Health Professionals; Nursing; Semantics. RESUMO Objetivo: Apreender a estrutura das representações sociais de trabalhadores(as) em saúde sobre o HIV/aids e compará-las com o subgrupo formado por médicas(os). Método: Pesquisa qualitativa fundamentada na Teoria das Representações Sociais. Coletaram-se evocações livres de 73 trabalhadores(as) de serviços públicos especializados em HIV/aids, em Salvador-Bahia, para o estímulo HIV/aids, submetendo-as à análise no software EVOC. Resultados: Para os(as) trabalhadores(as) em saúde, o HIV/aids associa-se a “preconceito, cuidado, doença e prevenção”, e para o subgrupo de médicas(os) ao termo “prevenção”. Os trabalhadores em saúde representam o HIV/aids de forma semelhante à sociedade em geral e, pelo seu caráter normativo, prescrevem atitudes aceitas como próprias de profi ssionais de saúde. Considerações fi nais: Os achados mostram que independentemente dos avanços da área da saúde, no tocante ao tratamento da aids, ainda persiste o preconceito. Tornase relevante o fortalecimento de ações interdisciplinares, para discussões sobre essa temática na formação, que favoreçam a integralidade da assistência. Descritores: Assistência; Síndrome da Imunodefi ciência Adquirida; Profi ssionais de Saúde; Enfermagem; Semântica. RESUMEN Objetivo: Aprehender la estructura de las representaciones sociales de los trabajadores de la salud sobre el HIV/sida y compararla con el subgrupo formado por médicos. Método: Investigación cualitativa fundamentada en la Teoría de las Representaciones Sociales. Se recolectaron evocaciones libres de 73 trabajadores de servicios públicos especializados en HIV/sida en Salvador, Bahía, para el estímulo HIV/sida, y se las analizó mediante el software EVOC. Resultados: Para los trabajadores de la salud, el HIV/sida está asociado a “prejuicio, cuidado, enfermedad y prevención”, y para el subgrupo de médicos, al término “prevención”. Los trabajadores de la salud representan el HIV/sida de manera semejante a la sociedad en general y, por su carácter normativo, manifi estan actitudes aceptadas como propias de los profesionales de la salud. Consideraciones fi nales: Los hallazgos demuestran que independientemente de los avances en el área de la salud, permanece el prejuicio en lo tocante


INTRODUCTION
Acquired Immune Deficiency Syndrome (AIDS) is a global phenomenon in public health.It causes considerable damage to the health of the population and is considered a milestone in the history of the world (1) .Due to the proportion it reached, the authors believe that AIDS has also become a social phenomenon, since it promotes wider debate on values linked to sexuality, morality, human rights, gender relations and life.
The complexity of AIDS as a social phenomenon, in its four decades of existence, is accompanied by achievements and advances.However, it still disturbs several spheres of society and can affect all without distinction (2) .
According to data from the Ministry of Health, despite its stability in the last five years, 798,366 cases of AIDS were reported in the country by the year 2015 (3) .The significant increase in the survival of people living with HIV/AIDS has required an expansion of multidisciplinary strategies to secure better living conditions and led to emergence of new psychosocial demands (4) .
However, because they are seen as socially deviant regarding the norm imagined by heteronormativity, people living with HIV/AIDS suffer prejudice, stigmas and discrimination, which make them vulnerable to social and health problems (5) .
As a chronic disease, AIDS imposed an obligation to reformulate the structure of health care and compelled health care professionals to discuss and present answers to questions that have not yet been properly explored in health care, such as sexuality, loss and death (6) .
In this sense, researchers (7) affirm that health professionals are responsible for providing a comprehensive quality care free of prejudice.In addition, it is their role to act as co-participants in the health-promotion process, guaranteeing all patients the right to be treated with respect, dignity, equality and justice, observing the SUS' principle of equity.
A study carried out with Colombian health professionals involved in sexual and reproductive health programs for adolescents concluded that the majority of the workers had adequate knowledge about HIV infection, had a positive attitude regarding the virus and demonstrated professional competence (8) .Working with a stigmatized disease generates demands that go beyond technical and scientific knowledge, giving rise to new models of relationship and care (9) .In addition, the social representation of the disease among health care professionals can interfere in the behaviors adopted.
Aiming to fill the gaps between theory and professional practice, this study will provide a dialogue with the workers in order to support their daily activities in health units that care for people living with HIV/AIDS (PLHA), specially addressing the social representation of HIV/AIDS and the impacts of such representation on care practices.

OBJECTIVE
To apprehend the social representation of HIV/AIDS among health care professionals and to compare it with a subgroup of physicians.

METHOD Ethical aspects
This research was submitted to the Research Ethics Committee of the UFBA Nursing School and was approved in 11/17/2014.This is a study linked to the multicenter research project coordinated by a professor at the State University of Rio de Janeiro, entitled "The transformations in health care and nursing in times of AIDS: social representation and memories of nurses and health professionals in Brazil".

Theoretical-methodological framework and type of study
This is a descriptive research with qualitative approach using the theoretical-methodological framework of the Theory of Social Representations (TSR).

Methodological procedure
The professionals working in the services included in the research were approached for individual application of the collection instrument, which was based on a word association test (WAT) with the term "HIV/AIDS".

Study setting
The study was conducted in four public services specialized in HIV/AIDS in the city of Salvador, Bahia.

Data source
Of the 90 professionals directly working in care in the selected units, either in health sciences (nurses, pharmacists, dentists, nutritionists, physicians and therapists) or humanities (psychologists, social workers), 73 were selected to participate in the research.
The inclusion criteria were: health professionals of both genders with at least one year of professional experience in the care of people with HIV/AIDS; and professionals active in the specialized service during the research.As exclusion criteria: professionals who were on vacation or leave.

Data collection and organization
Data was collected in November and December 2014.Each participant recalled three to five terms, which were tagged and then composed the corpus that was processed using the programs SELEVOC and COMPLEX from the EVOC 2005 software.The intersection between frequency and hierarchy of the terms allowed the construction of a table expressing the content and structure of the social representations (9) .

Social Representations of health care professionals on Acquired Immune Deficiency Syndrome
Suto CSS, Oliveira JF, Paiva MS.

Data analysis
The data was analyzed based on the corpus composed of the terms recalled by all 73 participants of the research and on another corpus, constructed only with the physicians.This allowed the COMPLEX software to compare the corpora.
Descriptive statistics, relative frequency and the mean recall order (MRO) were used to infer the probability of the terms being present in the central core of the social representation, according to their position in the table.The interpretation of the data was based on the theoretical assumptions of the structural approach of the TSR.

RESULTS
The results were presented considering the representation of all 73 workers (corpus 1) and of 15 physicians (corpus 2) based on the term "HIV/AIDS" and according to valuation, that is, after the classification of the terms in order of importance.In the context of social representations in a structural approach, this led to the identification in the central core of references to the historical, social and ideological context of each group, giving homogeneity to different representations of each corpus.
In response to the term "HIV/AIDS" and after ranking the terms in order of importance, the total number of workers recalled 355 terms, with mean recall order (MRO) of 2.9 on a scale of 1 to 5.Among the subgroup of physicians, 111 terms were mentioned, maintaining the same MRO.The terms with frequency equal to or less than 2 were excluded.After that, the mean recall frequency was set at 6 for all workers and at 3 for the subgroup of physicians.The combined analysis of these data resulted in Chart 1, provided by the software.

DISCUSSION
Chart 1 presents the elements that probably constitute the central core of the SR of the term HIV/AIDS.These elements are represented by the terms "care, disease, prejudice and prevention".For the group composed of physicians, the only term that appears in the central core is "prevention".It is worth noting that, for the group with all the participants, the term prejudice is the most important component, which demonstrates a fundamental contrast between the groups.It is possible that elements that appear in the central core with much higher frequency than the other components are the central elements of the representation (10) .Regarding the group with all the workers studied, the element "prejudice" corresponds to this definition.
Using relative frequency, we can affirm that 48% of the workers recalled the term prejudice.Among the physicians, this term represented 40% of the terms recalled.However, in the MRO chart (11) the term appears in the near periphery for the subgroup of physicians, demonstrating that it is also part of the representation and that it was or it will be present in the central core.
Chart 1 -Terms recalled based on the term HIV/AIDS, in order of importance, for all the participants (73) and for the physicians (15), Salvador, Bahia, Brazil, 2015 In the area of health, studies point to continuing education as a potentially viable strategy to improve current work conditions and create a workplace that promotes satisfaction and professional development.This strategy is consistent with the national AIDS policy, which also includes measures to prevent occupational exposure (9,12) .
The meaning attributed to a given object by a subject comes from information that continually reaches him in his practice and in his relationships (13) .Considering that the central core of social representations reflects social thought and corresponds to the identity and consistency of the social group (14) , the analysis of the central cores presented in Chart 1 reveals a discrepancy between the representations among the physicians and among the total number of workers.While the physicians focus on prevention, the other group evokes representational elements that accompany AIDS since its onset.
Social representations can be classified into three types: 1) hegemonic -conceptions widely shared by members of a group, which are not debatable and are part of the pillars of a society; 2) emancipated -produced in intergroup relations, they reveal the differences between divergent groups; 3) polemic -organized by two groups in conflict and not shared by society (15) .In this classification, the representations identified can be classified as emancipated.
The term "prevention" is also part of the central core of all the participants, but with a lower hierarchy, salience and accompanied by the terms "care and disease".Analyzing the set of terms in the central core of the representation for all the participants, we can infer that the contextualization takes place both in the field of reified knowledge and of hegemonic representations.This way, it is possible to affirm that the subjects of this study attribute to the object a complexity of meaning.The representation encompasses biological aspects, showing a similarity with the scientific knowledge of professionals in the health area, and social aspects, which are similar to the meanings attributed by society in general.
The terms appearing in the core of the representation of all workers refer to "effects" (disease) and point to activities peculiar to health professionals, such as "care and prevention".This way, the figurative core "after modeling" is related to the current context of AIDS, which is currently conceived as a socially acceptable phenomenon.
The social representations of AIDS are based on dominant ideologies, such as those of colonialism and heterosexism.Thus, hegemonic representations, in any field, are at the service of power relations (16) .
In this sense, we agree that, thirty years after the beginning of the epidemic and its impact on the world, AIDS is now considered as a chronic disease (17) .This new classification, for the authors, is justified, since the disease leads to physical and psychological limitations and suffers the direct impact of its stigma.However, since interpretations and representations of diseases are influenced by their time, the meaning given to AIDS can continue to be reformulated.Moreover, depending on the context of the production of representations, they can symbolically differentiate themselves in their content (18) .
The other words evoked by all the participants, which appear in the near periphery, are "ignorance and treatment".For the physicians, they are "care, prejudice and suffering".These words reveal professional attributions (treatment, care) and concern with the complex and relatively new social phenomenon (ignorance, prejudice and suffering).From this, it is possible to infer that there is a similarity between groups regarding the psycho-affective attributes of this representation.
The term "care" deserves prominence in the context of this research.For the group with all workers, this term appears in the central core with the second MRO, along with the terms "prejudice, prevention and disease".On the other hand, for the physicians, it appears in the near periphery along with "prejudice and suffering".Considering the term HIV/AIDS and the insertion and proximity of the term care in Chart 1, it is not impossible to say that the meaning of the term care is close to "submit to rigorous analysis" or even caution with a "threat".
A study carried out in the Southeast region of Brazil relating SR and occupational risk in AIDS found that the representations of health workers, besides being made up of elements of scientific knowledge, were psychosocially constructed and integrated into their everyday life (19)(20) .Thus, it would be pertinent to point out that the terms "ignorance and suffering", present in the near periphery in Chart 1, may be related to the structural and/or organizational conditions in the work units or to the weariness and lack of problem-solving capacity in the work performed.
It is worth noting that the problem of AIDS involves those who work in health, whether as natural people or as workers.In the condition of health workers, due to predisposition to accidents with sharp materials, the proximity with the consequences of the disease leads to a type of representation still present today, in which AIDS is strongly associated with death, prejudice and exclusion (20)(21) .
The terms "treatment and care" are directly related to the introduction of the antiretroviral therapy, which has fundamentally contributed to the classification of AIDS as a chronic disease.It means that if the disease is handled and treated properly, the probability of illness and death for people living with HIV/AIDS considerably decreases.In addition, scientific evidence indicates that the treatment is effective not only for controlling the disease and improving the quality of life, but also for reducing the transmission of the virus (22) .
In the third quadrant, considered as the near periphery, the elements presented are called contrast elements and explain the existence of a representational subgroup.In this cell, the terms "difficulty, chronic disease and epidemic" confirm, in a certain way, that the physicians represent a different subgroup in the sample of this study, which had already been pointed out by the central cores of the representation.
Social representations have essential roles in the dynamics of social practices and relations (23) .These functions are called by the author as knowledge, identity, orientation and justification.Thus, SRs, in addition to provide understanding and explanation, also define the identity of a group, directly influencing the process of socialization of its participants.
One of the most striking features of social memory is that, although the past itself constitutes its raw material, the psychosocial process of its construction is subordinate to the interests and needs of the present (24) .Therefore, this is a possible explanation for the maintenance of the terms "difficulty, chronic disease and epidemic" in the near periphery of the physicians.
Other elements in the larger group such as "reception and vulnerability" carry positive aspects, such as propositions to cope with the disease.These elements were possibly incorporated with the perspective of promoting humanized care, with a re-signification of AIDS by its association with the new nomenclature proposed by the national policy of humanization.As for the terms "physical degradation, fear and suffering", they date back to the beginning of the epidemic and exemplify the term with the highest hierarchy in the core, "prejudice".
Psychosocial representations, such as fear of HIV infection, are related to the fear of the AIDS epidemic, which in turn is originated in the ancient metaphor of a pestilent and devastating death.As individuals, we do not believe that it is possible to free ourselves from all conventions or that we can extinguish all prejudices (21,25) .The knowledge gained about the epidemic over the last four decades is still filled with fear and stigma.
In the distant periphery, in which the terms have a low and high MRO and are recalled by a small number of participants, the terms "counseling, adherence-treatment, love and help" appear for the general group, which is aligned with the current vision of AIDS.Social support, along with information and guidance, has been functioning as a good course of action.However, the distant periphery in the physicians' subgroup is incompatible with this perspective, bringing only the term "death", which is actually a situation that presented a considerable reduction.It is worth noting that a study on risk and vulnerability (26) showed that physicians have historically been involved in struggles to overcome disease and death of patients, which can also be extended to other professionals, justifying the presence of this term in the two groups studied.
The tables were different in their structural configuration and homogeneity.The social representation of all the workers has a more dispersed configuration, with a redundancy of themes due to the variety of terms.It is considered heterogeneous and incorporates basically psychosocial aspects.In the physicians table, the configuration is cohesive, synthetic, with information on few main themes, and characterized by focus on the disease.

Limitations of the study
This research has a significant scope regarding the field and the participants in the context of its production.However, its limitation in a single municipality does not allow generalizations regarding the topic addressed.

Contributions to the area of nursing, health or public policy
The results are significant for the analysis of the care offered in specialized units and can be used with other groups in theoretical comparisons related to the theme.In addition, evidence of persistent negative feelings about HIV/AIDS reveals aspects of the memory of social representations linked to the contexts and experiences of the onset of the epidemic, which need to be overcome in order to improve care for people living with HIV/AIDS.

FINAL CONSIDERATIONS
The main evidence refers to what was common in the representations of both groups: prejudice is an important element in the constitution of the social representation.In addition, AIDS remains associated with death, suffering and ignorance, similar to previous decades.
Considering only the central cores, the meanings attributed to AIDS reveal a discrepancy between its representation among physicians and among all the workers, characterizing them as distinct representations.
The findings show that, despite the advances in the health area regarding treatment for HIV/AIDS, there is still prejudice among health professionals.This representation can have an impact on the health care provided to people living with HIV/ AIDS.Therefore, it is important to strengthen interdisciplinary actions to discuss this theme in formal education and in inservice training, providing moments of exchange of information and clarification of doubts and leading to rupture of stereotypes and comprehensiveness of the assistance.

FUNDING
The National Council for Scientific and Technological Development (CNPq) granted funding for the multicenter project and the Research Support Foundation of the State of Bahia (FAPESB) granted a master's degree scholarship, which facilitated and encouraged this research.