Vulnerability of women in common-law marriage to becoming infected with HIV/AIDS: a study of social representations

Abstracts

O artigo discute as representações sociais de mulheres em união heterossexual estável no que diz respeito à vulnerabilidade à infecção pelo HIV/AIDS. Os dados foram produzidos pela associação livre de palavras e constituem recorte de uma pesquisa fundamentada na Teoria das Representações Sociais desenvolvida com mulheres soronegativas para o HIV, da capital e interior da Bahia. A análise fatorial de correspondência revelou significância para as variáveis: procedência, escolaridade e tempo de união estável. A aceitação à traição emergiu como fator de vulnerabilidade para respondentes com 1-5 anos de união estável do interior. Mulheres da capital com 6-10 anos de união estável representam a monogamia como forma de prevenção. Mulheres com maior tempo de união e nível escolar básico representam-se como invulneráveis, contrárias as que têm 1-5 anos de união e escolaridade mediana. Os resultados indicam a necessidade de mais ações com o objetivo de desnaturalizar as coerções sócio-culturais que geram representações e aproximam mulheres em união estável da AIDS.

Mulheres; Síndrome de Imunodeficiência Adquirida; Gênero e saúde; Vulnerabilidade em saúde

ARTIGO ORIGINAL

Vulnerability of women in common-law marriage to becoming infected with HIV/AIDS: a study of social representations^*

Vulnerabilidad de mujeres en unión heterosexual estable a la infección por VIH/SIDA: estudio de representaciones sociales

Larissa Silva de Abreu Rodrigues^I; Mirian Santos Paiva^II; Jeane Freitas de Oliveira^III; Sheva Maia da Nóbrega^IV

^IRN. Master in Nursing, Federal University of Bahia. Specialization Degree in Public Health, Instituto Brasileiro de Pós-graduação e Extensão. Assistant Professor, Universidade do Estado da Bahia Guanambi, BA, Brazil. [e-mail]

^IIPh.D. in Nursing, University of São Paulo. Post-Doctorate in Psychology, Instituto Superior Ciências do Trabalho e da Empresa. Associate Professor, Federal University of Bahia. Salvador, BA, Brazil. [e-mail]

^IIIPh.D., Professor, Federal University of Bahia, Graduate Program in Nursing. Member of the Study Group about Sexualities, Vulnerabilities, and Gender, College of Nursing, Federal University of Bahia. Salvador, BA, Brazil. [e-mail]

^IVMaster in Social Psychology, Federal University da Paraíba. Ph.D. in Social Psychology, Ecole des Hautes Etudes en Sciences Sociales. Diplôme d'Études Aproffondies pela Ecole des Hautes Etudes en Sciences Sociales. Professor, Federal University of Pernambuco. Recife, PE, Brazil. [e-mail]

Correspondence addressed

ABSTRACT

This article discusses the social representations of women living in common-law marriage in terms of their vulnerability to becoming infected with HIV/AIDS. Data were obtained through the free association of words, and consisted of an excerpt of a study founded on the Social Representations Theory developed with HIV-negative women living in the state capital and cities in the interior of Bahia. The correspondence factor analysis showed significance for the variables: origin, education level and time spent in common-law marriage. Their acceptance of marital affairs emerged as a vulnerability factor for respondents with one to five years spent in common-law marriage, living in cities in the interior. Women from the capital, with 6-10 years spent in common-law marriage, reported monogamy as a form of prevention. Women with a longer common-law marriage who had completed only a primary education reported feeling invulnerable, which was the opposite of those with one to five years in common-law marriage with a secondary education. Results show there is a need for more interventions aiming to denaturalize the socio-cultural coercions that generate representations and make women in common-law marriages more vulnerable to AIDS.

Descriptors: Women; Acquired Immunodeficiency Syndrome, Gender and health; Health vulnerability

RESUMEN

Se discuten representaciones sociales de mujeres en unión heterosexual estable, respecto de vulnerabilidad a infección por VIH/SIDA. Datos generados a partir de asociación libre de palabras, constituyéndose en muestra de investigación fundamentada en Teoría de las Representaciones Sociales, desarrollada con mujeres seronegativas para VIH, de capital e interior de Bahía. El análisis factorial de correspondencia reveló significatividad para: procedencia, escolaridad y tiempo de unión. La aceptación de la traición surgió como factor de vulnerabilidad para participantes con 1-5 años de unión estable del interior. Las mujeres de capital con 6-10 años de unión representan a la monogamia como forma de prevención. Mujeres con mayor tiempo de unión y escolaridad básica se auto-representan como invulnerables, al contrario de aquellas con 1-5 años de unión y escolarización media. Los resultados sugieren aumentar acciones para desnaturalizar coerciones socioculturales que engendran representaciones y favorecen la exposición de la mujer en unión estable al SIDA.

Descriptores: Mujeres; Síndrome de Inmunodeficiencia Adquirida; Género y salud; Vulnerabilidad en salud

INTRODUCTION

People's susceptibility to AIDS pervades contexts of vulnerability and gender issues that have, over the years, marked changes in epidemiological patterns, including groups, initially not considered susceptible, such as women in a heterosexual common-law union or married.

The concept of vulnerability, originated from the field of Human Rights, entered the health field in 1992, and considers that the exposure of people to disease results from their interaction with aspects that involve three closely interconnected dimensions: personal, programmatic and social⁽¹⁾. The multidisciplinary character of vulnerability includes the simultaneous detection of weaknesses and the capacity to face health problems/diseases thus permitting to make innovations in health care and to meet the health needs besides the physical, clinical and biological issues⁽²⁾. Therefore, the incorporation of the concept of vulnerability can contribute to renewing nursing practices⁽³⁾ in the search to meet the needs of individuals and/or specific groups.

AIDS, from the perspective of vulnerability, uncovers nuances and contradictions that outline the gender and power relationships existing between men and women in different contexts. The concept of gender as a system of signs and symbols that denotes the relationships of power and hierarchy between genders and in relationships between people of the same gender⁽⁴⁾ permits to recognize the impact that power relationships have on the health of different social groups, and redirect and prioritize the care in the everyday practice at health units⁽⁵⁾.

The social and cultural constructions regarding masculinity and femininity, across social classes, races, generation and culture gaps establish different vulnerabilities for individuals and/or groups living in the same society as well as those in different settings. The heterosexualization and feminization of the epidemics are related, namely, to the structures of thoughts, conceptions and representations that determine, among other behaviors, not using condoms in the marriage context⁽⁶⁾.

The social representation of AIDS as a "disease of others" determines the distance that people and/or population groups keep from the behaviors that permit to prevent the disease, including safe sex. The association of AIDS to a risk group, influenced by educational campaigns that emphasize sexual behaviors in the susceptibility to HIV, determines that people, in general, define themselves as being free from the possibility of becoming infected, therefore compromising the adoption of prevention measures⁽⁷⁾.

Studies about the perception that married women and women in common-law have about the preventive measures against HIV/AIDS are scarce, and they emphasize on the interface between the meaning of infection and becoming infected with HIV and the moralities related to marriage and the roles assumed by the partners⁽⁸⁾. A study performed with women living in common-law found that their trust in their partner represented a frequent explanation for their not using condoms and thus constituting a factor of vulnerability for both⁽⁹⁾. A similar situation was found in the study performed with women living in a slum (favela) in São Paulo, Brazil⁽¹⁰⁾.

Considering the time spent in marriage/common-law as safe or not is a form of recognizing the everyday events based on explanations from positive beliefs regarding the social status of the marriage, conditioning unsafe behaviors in both men and women⁽¹¹⁾.

In this sense, a study was performed with the objective of learning the social representations of women in a heterosexual common-law union, living in different social contexts, regarding their vulnerability to becoming infected with HIV/AIDS. The study was formulated with the presupposition that the social relationships affect the behaviors of people in different social contexts, exposing them or not to vulnerability situations for certain diseases.

METHOD

The data consist of an excerpt from a descriptive and exploratory study using a quanti-qualitative approach, performed with married women who were HIV-negative or unaware of their being infected or not, because they have never been tested for HIV, and lived with their current partner for over one year.

The study was developed in compliance with the ethical principles of Resolution 196/96 of the National Health Council. The project was approved by the Research Ethics Committee of the College of Nursing, Universidade Federal da Bahia (Review number 48/2008) and Universidade Estadual do Sudoeste da Bahia (Review number 217/2008).

The participants were first contacted when the researcher included herself in the family planning program of two basic health care units in different cities in the state of Bahia: Salvador, the state capital, and Jequié, located in the mid-south region, 365 km away from the capital. Salvador comprises 51% of all notified AIDS cases in the state, whereas in Jequié 223 cases had been registered with the Centro de Referência em Saúde Sexual e Reprodutiva (reference center in sexual and reproductive health) from 2002 until October 2009.

From February to May 2009, in both cities, after consulting with the nurse, the women were invited to participate in the study. After explaining the study, the participants were handed the Free and Informed Consent Form so they could read and sign it, in compliance with Resolution 196/96 of the National Health Council. A total of 195 women agreed to participate in the study and answer the free association of words test; 100 women lived in the state capital and 95 lived in the interior city.

The participants' social representations regarding their vulnerability to becoming infected by HIV/AIDS occurred by applying a set of techniques appropriate to the qualitative study founded on the Theory of Social Representations, however, this article addresses the data collected by the free association of words technique. This projective technique was adapted for social psychology, and it permits to build awareness about unconscious elements through behaviors, evocations, i.e., the structure of the subject's personality⁽¹²⁾.

The instrument used in this study comprised sociodemographic data of the participants and four stimuli: Aids, man and Aids, woman and Aids and yourself. The definition of these stimuli occurred due to the need to identify how the women expressed their concerns regarding AIDS, men's and women's vulnerability and, also, where they stand in this context. The free association of words test was applied individually, and the stimuli were presented one at a time and a registry was made of the first five words that were evocated. The average test application time was four minutes for each participant.

The data emerged from the free association of words test were subjected to correspondence factorial analysis (CFA) using Tri-deux-mots software, version 2.2, considering a frequency of eight or more for each inductive stimulus. Data processing requires specific organization between the fixed or socioeconomic variables of the informants (origin, education level, religion, time spent in marriage), established previously, and the opinion variables presented by the women for the inductive stimuli (AIDS, man and AIDS, woman and AIDS, and yourself). The following possibilities were considered for the fixed variables: origin (capital or interior), education (primary education, secondary education), religion (evangelic, catholic, no religion) and time in marriage (1 to 5 years; 6 to 10 years; 11 years or more).

Data processing using Tri-deux-mots yields a graph that permits to visualize the opinion and fixed variables with statistical significance and the differences between the studied groups. The graph is not self-explanatory and analyzing it requires knowledge and skills regarding the theory of social representations to understand the meanings of the opinion variables evoked for the presented stimuli.

As an attempt to make it easier to understand the free words association test data processed by the Tri-deux-mots, we initially present the opinion variables for each stimulus in a correlation with the fixed variables that showed statistical significance. Next, we will present the interpretation of the data revealed by the graph.

RESULTS

The data processing using the Tri-Deux-Mots software revealed different sets of evocations for each inductive stimulus associated to the women's different marriage/common-law periods, origin, and education level. The fixed variable religion did not appear on the chart, which shows there it has no statistical significance with the other variables.

The evocations that showed statistical significance for the group of women who have been in a common-law marriage for over 11 years, and had only a primary education, and living in Salvador, for the four stimuli were: incurable, dangerous, partner, and care for stimulus 1 (Aids); transmissible disease, care, sex, exams, and condom use for stimulus 2 (man and Aids); hygiene, exams, transmission of disease and sex for stimulus 3 (woman and Aids) and, death for stimulus 4 (yourself).

Women with a secondary education and 6 to 10 years spent in common-law marriage, the statistically significant words for each stimulus were: stimulus 1 (Aids) - transmissible, sex, despair, and suffering; stimulus 2 (man and Aids) - promiscuity, carelessness, lack of knowledge, sadness, and love; stimulus 3 (woman and Aids) - knowledge, prevent and death; stimulus 4 (yourself) - responsible, health, love and faith in God.

Among the evocations pronounced by the group from Salvador, who had from 6 to 10 years spent in common-lay, the statistically significant ones were: for stimulus 1(Aids) - betrayal, for stimulus 2 (man and Aids) - sad, shameless, exam, care and condom; for stimulus 3 (woman and Aids) - sad, irresponsibility and promiscuity and, for stimulus 4 (yourself) - exam and single partner, health and faith in God.

For the group of women with 1 to 5 years in common-law marriage, living in the interior of Bahia, the statistically significant groups of words evoked for each stimulus were: stimulus 1(Aids) - prejudice, suffering, preoccupation, danger, carelessness, prevention; stimulus 2 (man and Aids) - fear, betrayal, partner, carelessness; stimulus 3 (woman and Aids) – knowledge and fear, and for stimulus 4 (yourself) only the term fear.

DISCUSSION

Implications that time in a heterosexual common-law marriage and education level have on the women's social representation regarding their vulnerability to HIV/AIDS.

The interpretations of the evocations expressed by the group of women with a longer time in common-law and lower education level, regardless of their origin, lead to the idea of recognizing the incurable and transmissible nature of AIDS and the need to adopt preventive measures. The construction of this idea may be anchored on the information disseminated by the media and health care professionals that, in general, have emphasized on the care, particularly regarding condom use as an important strategy to avoid AIDS.

The reported care measures – hygiene, being tested, and using a condom – are presented as behaviors that should be adopted differently by women and men. The evoked opinion variables reproduce social and cultural constructions that establish different roles and functions for men and women in a way that hygiene care and performing periodical exams to check their sexual health and prevent diseases are considered to be a responsibility of women, while condom use is a behavior exclusive to men. These representations reveal gender issues translated into the multidimensional understanding and dynamics of what it means to be a man or woman within specific social contexts⁽⁸⁾.

The opinion variable death, evoked for stimulus 4 – yourself – reveals the women's fear of AIDS and their recognizing that there is still no cure and that it can kill. The statistical significance presented for the term death suggests the idea that AIDS is not a distant threat for the group of women with a longer time in marriage and lower educational level. The idea that AIDS is a disease of others^(6-7) still prevails; however that other is no longer so distant, which denotes the need for permanent care to remain far from the risk of becoming infected with AIDS and die.

The opinion variables evoked by this group of women reveal that the longer time spent in common-law and the low education level place them in a situation of vulnerability towards AIDS due to the predominance of ideas supported on social and cultural constructions that denote a subordination of women to men and by the reproduction of disseminated information, particularly by the media, in the beginning of the epidemics. The data highlight the need for educational activities that meet the specificities of population groups and respect the sociocultural differences between groups⁽¹³⁾.

The opinion variables evoked by the group of women with a secondary education and time spent in common-law ranging between 5 and 10 ten years emphasized the affective aspects that surpass the pragmatic, biological, and normative view of scientific knowledge regarding AIDS. They recognize the possibility of sexual transmission, however, this transmission is associated with the partner having a marital affair and therefore causes situations of despair and suffering. The evocations presented suggest that marital affairs cause much more despair and suffering that the disease itself. The disease is the confirmation of the unfaithfulness, masculine promiscuity, and the female submissiveness to the socially and culturally established male behaviors.

The objectification of masculine promiscuity related to AIDS is associated to the process of figuration in which behaviors and lifestyles establish the disease and permit to see the individual, assign meanings, and explain the social phenomenon⁽¹⁴⁾. In this group's conception, men's and women's vulnerability to becoming infected with AIDS relates, above all, to their level of (lack of) knowledge. When encouraged to assume a position in the AIDS context, they anchor their prevention on responsible attitudes, in the affective dimension (of love as cultural value) and religiousness. Perhaps this fact is not an indication of a representation of their own vulnerability to becoming infected with HIV/AIDS, however, it represents and advancement, considering that even with little involvement they question themselves in the context of the epidemics.

The group with a secondary education and time in common-law between five and ten years reveals vulnerable to the transmission, as their feelings of love prevail (when thinking about themselves and their partner) in the marriage. According to psychology, love is defined as a one person's feeling towards another that makes the former desire to give and receive from the latter sexual pleasures (referring to adults), tenderness, admiration, cooperation, understanding, protection or at least many of these satisfactions⁽¹⁵⁾. In this perspective, love presupposes the surrender of one to the other, and in sexuality this representation can influence a behavior of abandoning safe sexual practices, such as condom use, and make women, particularly, feel safe⁽⁸⁾.

The reproduction of the idea that the males' nature requires a variety of partners and that the husband has needs that can be met outside the family environment favors the women's vulnerability, as women tend to worry less about this situation in order to avoid changing an attitude that is prevalent in society into a personal conflict⁽¹⁶⁾.

The different set of opinion variables presented for the inductive stimuli point that the time in common-law and the education level assign different vulnerability situations for women in terms of AIDS, which are permeated, above all, by the reproduction of ideas that determine different behaviors between men and women.

Furthermore, the evocations of women with a lower educational level and who have spent a longer time in common-law reproduce the knowledge disseminated by marketing campaigns for normative prevention, with little involvement in the issue, while the representations of women with a higher education level and less time spent in common-law are permeated by affective issues due to the preponderance of their love for their partner.

The implications that the origin and time in a heterosexual common-law marriage have on the women's representations in terms of their vulnerability to HIV/AIDS.

The group originating from the state capital and with six to ten years spent in common-law marriage represents the vulnerability to HIV/AIDS due to marital affairs. The man and Aids representation is related to men's "uncontrolled" sexuality. This representations demonstrated that male sexuality has been developed in a way that it sustains the conviction, by part of these women, that men are naturally unfaithful and their sexuality is more intense than that of women⁽¹⁷⁾. Furthermore, the infective characteristic assigned to male sexuality is also expressed by men's relationship with prostitution⁽¹⁸⁾.

The stimuli women and AIDS was represented by the Salvador group with six to ten years spent in common-law marriage, based on the risk group approach. For this group, women who are or can become infected with AIDS, are irresponsible and have promiscuous behavior. Therefore, these women present a dichotomized representation regarding women and AIDS. On one hand, she is careful and precautious, having a single partner, an attitude diametrically opposed that when she thinks about the other woman, assuming an attitude of accusation, stating promiscuity, irresponsibility and a degradingly sad situation.

The construction of the representations by the group of women from Salvador and with six to ten years spent in marriage in terms of their vulnerability to HIV/AIDS gave evidence of the influence of sexist and patriarchal constructs considering that women associate sex to marriage as a social model. In this context, women relate the fact of being married and having a single partner to a form of protection against AIDS^(9-19). Opposite to the ideas of the social imaginary, HIV-positive women do not have a number of partners significantly different from HIV-negative women⁽²⁰⁾.

Through the representation of their perspective of having a single partner and believing in God, the capital group assumes a relatively distant position from being infected by HIV/AIDS. Unexpectedly, and also apparently contradictorily, the capital group expresses conservatism in their representations, which can be explained for their being married for a longer period compared to the other group.

On the other hand, the group with less time in common-law, and originally from the interior of the state, highlights suffering and prejudice as the aspects of living (or dealing) with AIDS. Marital affairs permeate the social imaginary of the group as a possibility of determining greater vulnerability when the partner is careless with prevention. Their representations disregard the gender, social, and programmatic vulnerabilities, which are broader issues that permeate and exceed those behaviors⁽¹⁾.

This same group represents women and themselves in the context of AIDS as fear, which demonstrates the passive attitude towards their personal protection, considering they assign more importance to their social role of wife, whose sexual life is submissive to men, as the primary function of satisfying her partner's sexual needs.

Social categories such as gender, are seen as naturalized, reified and, consequently, operative and resistant to change⁽¹⁴⁾. The social context in which gender differences are included, in cultural, social and economic terms, permeate the construction of social representations in a two-way movement, considering that one determines the other.

In summary, women from the interior feel safe and assume an accusative attitude towards their partner in terms of marital affairs, revealing to be afraid of becoming infected, because they do not have effective mechanisms to protect themselves. In psychology, fear corresponds to an emotion triggered by a stimulus that have the value of danger for the organism and reduces its defenses causing behaviors of fright or flight⁽¹⁵⁾. This group, therefore, evidences a submissive attitude towards their partner, despite being the bearer of their fear towards becoming infected with HIV/AIDS.

CONCLUSION

Both differences and similarities were observed between the studied groups, regarding the social representations in terms of their vulnerability to AIDS. This confirms the dynamics of social representations, and the influence that the women's origin, education level, and type of marital union have on their vulnerability. Nevertheless, the specificities of the groups, and the adopted methodology are not sufficient to generalize the results to the female population living in similar situations.

The present study results shed new light in terms of the socio-cultural differences of the settings experienced by women living in common-law, which evidences the influence that their origin has on their vulnerability to becoming infected with HIV/AIDS.

The opposition disposition revealed by the data analysis gave evidence of the gender valorizing contents for women with a longer period spent in common-law marriage and living in Salvador, to which the representations of AIDS are associated with women's promiscuity and irresponsibility, a group they consider to be apart and protected from because they have a single partner. For women living in cities of the interior of Bahia, the representation of AIDS is associated to marital affair, which is characterized as a socially and culturally established behavior. Interestingly, both groups minimize the male responsibility with adjectives referring they are imprudent and that the power of condom use is exclusive to men.

Through the identified social representations, we observe the presence of ideas, values, beliefs and social construction that at times facilitate and at others hinder the practice of prevention. Therefore, educational programs and activities gain utmost importance as a form of valuing or discouraging the referred representations, considering the contextual factor implied.

By analyzing these representations, from a gender perspective, we highlight the need to promote intersectoral interventions not only to improve comprehension regarding the vulnerability of married women to HIV/AIDS, but, most of all, to provide the economic, social, and political conditions to overcome the power inequalities of those women.

Furthermore, it is important to problematize and denaturalize the experiences of women living in common-law regardless of their origin. In this context, we highlight the role of health care professionals, particularly of the nursing team, in performing educational activities with women based on giving information that would help clarify the factors that increase the vulnerability of women living in common-law to AIDS.

We stress, however, that the problematization of social, political, religious and cultural coercions that create and increase the vulnerability of women in common-law to AIDS should not be limited to health. This subject deserves being discussed and valued in other fields such as education, in order to promote effective changes. Therefore, the present study findings can provide an increment for the implementation of more effective educational interventions in the prevention and battle against AIDS.

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Correspondência:

Larissa Silva Abreu Rodrigues

Av. Rio Branco, 283 – Centro

CEP 45203-011 – Jequié, BA, Brasil

*

Extraído da dissertação "Representações de mulheres em união heterossexual estável sobre vulnerabilidade à infecção pelo HIV/Aids, Universidade Federal da Bahia, 2009.

Publication Dates

• Publication in this collection
  07 May 2012
• Date of issue
  Apr 2012

History

• Received
  29 Apr 2010
• Accepted
  04 Oct 2011