Beliefs of older adults about their vulnerability to HIV / Aids , for the construction of nursing diagnoses

Objective: to know the beliefs of older adults about their vulnerability to HIV/Aids, and to identify nursing diagnoses. Method: a fi eld research implemented in Family Health Units, in João Pessoa, Brazil. The sample included 250 older adults of both genders with data collected from April to July of 2011. A Test of Free Word Association was applied using the term HIV/Aids. A content analysis and cross-mapping of the most frequent terms with the International Classifi cation for Nursing Practice, 2011 were performed. Results: 202 terms were identifi ed in terms, with an overall frequency of 1156. Of the 202 terms, 16 were more frequent and were used to construct the nursing diagnoses. The diagnoses identifi ed were knowledge about appropriate sexual behavior, ability for partial protection, fear of death and hopelessness. Conclusion: understanding these beliefs drew from knowledge about factors related to, vulnerability to HIV/Aids aimed at planning health care actions for this population segment.


INTRODUCTION
Aging is characterized by progressive biological, psychological and social changes over the life of a human being.In Brazil, a widening top of the population pyramid is noted, due to a growing relative participation of the population aged 65 and over, which was 4.8% in 1991, rose to 5.9% in 2000, and reached 7.4% in 2010.Therefore, the absolute growth of the Brazilian population over the last ten years has occurred due to a growth of the adult population with a more prominent increase in the elderly population (1) .
The population longevity is due to different aspects, including: increased life expectancy, decreasing birth rate, improved quality of life, advances in health care and technologies that contribute to heathy aging, with quality of life and maintenance of sexual activity (2) .
The active sexual life of older adults is influenced by advances in the pharmaceutical industry through the use of medications to treat erectile dysfunction, concurrent with the demystification of sex, resulting in a greater vulnerability to sexually transmitted infections, such as human immunodeficiency virus (HIV), in this age group (3) .
In the past, the sexuality of older adults has been denied and forgotten, which created significant changes associated with socio-cultural aspects, such as attitudes and information considering the changes resulting from biological transformations.Therefore, it must be understood that sexuality not only remains, but is transformed throughout life, and that each age favors different forms of sexual satisfaction.In this context, some factors regarding sexuality in older age must be considered, such as: more older adults require care and attention regarding sex; the need for sex education for this population; a new view of these subjects, who are people with rights, particularly in the area of sexuality (4) .
The changes resulting from sexual behavior in older age have demanded changes in the epidemiological profile of Aids.Although most cases of HIV infection are detected in the age group between 15-49 years, a significant increase in the incidence rate of this infection has been occurring in the population group over 50 years of age.According to the United Nations for the Prevention and Control of Aids (UNAIDS), 40 million people are estimated to live with HIV/Aids worldwide, approximately 2.8 million aged less than 50 years (5) .
In Brazil, the number of diagnosed individuals has been increasing in the age group above 60 years.There is an increase of Aids cases in both genders, which rose from 394 in 1999, to 938 in 2009, in males, and from 191 in 1999, to 685 in 2009, in females (6) .
In the social perspective, the possibility of an older adult being infected with HIV appears to be unlikely, since sexual activity is a prerogative of youth.However, it should be noted that older people can be sexually active, which requires consideration of the possibility of sexually transmitted diseases (2) .Therefore, studies are needed to address behavioral aspects, opinions and knowledge from the perspective of older adults, in order to plan preventive actions, especially because of the vulnerability to HIV/Aids.
The conceptual framework of vulnerability consists of three interdependent plans of determination, and consequent seizure of higher or lower individual and collective vulnerability.The meaning of the term vulnerability refers to the chance of exposure of people to illness as a result of various aspects that immediately relate to the individual.However, the chances of illness also refer to the social and political context.The behaviors generating an opportunity of acquiring an infection or disease cannot be understood only as a consequence of the will of individuals, but are linked to the degree of awareness that they have about the effects of behaviors, and the power to transform them effectively from that awareness (7) .
The approach to sexuality in older age, and vulnerability to HIV infection, consists of a health overview that generates professional challenges during planning of health care for the elderly.For nurses, identifying nursing diagnoses enables identification of common problems and health care needs of this population group.Therefore the discussion about knowledge and behaviors of older people regarding HIV/Aids, based on nursing diagnoses, generates an assessment of health care needs and factors that make the elderly vulnerable to HIV/Aids, aiming to support planning of actions in the health care service.
To identify the nursing diagnoses, the International Classification for Nursing Practice (ICNP ® ) was used in this study, which is an information tool to describe and provide data on the representation of nursing practice in the Health Information Systems.It is consolidated worldwide as a unified nursing language that can communicate and compare data across different contexts, countries and languages (8) .

OBJECTIVE
To understand belief about vulnerability to HIV/Aids of older adults, based on the concept of vulnerability (7)   , and to identify nursing diagnoses from these beliefs, based on the ICNP ® 2011.

METHOD
This was field research with a qualitative approach, conducted in Family Health Units in João Pessoa, Paraíba (Brazil).
This study was linked to the project, Older adults' health conditions, quality of life and social representation in Family Health Units, funded by FAPESQ-PB/Ministry of Health/ CAPES, and approved by the Ethics Committee at Lauro Wanderley University Hospital, Protocol 261/09.comprensión de conceptos trajo reflexiones sobre factores de vulnerabilidad ante el HIV/Sida en vista de planificación de acciones la salud para este segmento de población.Palabras clave: Salud de los Ancianos; VIH; Síndrome de Inmunodeficiencia Adquirida; Diagnóstico de Enfermería.
A non-probabilistic convenience sample was used, consisting of 250 elderly men and women, selected based on the following inclusion criteria: aged 60 years or older; receiving care at the Family Health Units; having the cognitive ability to respond to the instrument.As an ethical criterion, the elderly who agreed to participate in the research by signing the Terms of Free and Informed Consent were included.
Data were collected from April to July of 2011, through semi-structured interviews with the application of the Free Word Association Test (FWAT) (8) , using the inductive term HIV/ Aids and socio-demographic variables (age and gender).The interview was conducted according to an individual schedule, when the older adults were asked to associate five words to the inductive term HIV/Aids.Data regarding gender and age were analyzed using the SPSS software, version 11.0, and data regarding the semantic group of words were analyzed in three distinct stages, setting up a triangulation of data analysis techniques: content analysis, cross mapping with the ICNP ® 2011 terms, and construction of a conceptual map.
In the first stage, data were prepared in a database that included the words associated with the inducer term, HIV/Aids, using the categorical thematic content analysis technique (10) , based on the following steps: creation of the corpus, consisting of 250 interviews; selection of the context and record units defined for this study, the word; cutting; coding; grouping and pre-established categorization according to the concept of vulnerability (7) and subcategories arising from the content analysis of the words of the older adults.The thematic categories and subcategories were divided into: Category 1 -cognitive conditions, and subcategories: access to information, recognition of susceptibility, and effectiveness of the prevention methods; Category 2 -behavioral conditions, and subcategory: desire and ability to modify behaviors that define susceptibility; Category 3 -social conditions, and subcategories: access to resources, and ability to adopt protective behaviors.
In the second stage, the frequency of the terms spoken by the elderly was identified.A cross-mapping was performed with the most frequent terms with the ICNP ® 2011 terms.For the crossmapping, the ICNP ® seven-axis model was used, defined as: Focus: the area of attention that is relevant to nursing; Judgment: clinical opinion or determination related to the focus of nursing practice; Means: a manner or method of accomplishing an intervention; Action: an intentional process applied to a client; Time: the point, period, instance, interval or duration of an occurrence; Location: anatomical and spatial orientation of a diagnosis or intervention; Client: subject to which a diagnosis refers and who is the recipient of an intervention.Based on these axes, the most frequently used terms were organized to identify nursing diagnoses (9)   .For the construction of the nursing diagnosis, the terms in the Focus and Judgment axes were used.
In the third step, the categories and subcategories of the study, as well as the identified nursing diagnoses, represented the beliefs of the elderly about vulnerability to HIV/Aids, and were placed into a conceptual map.For the construction of the conceptual map, Cmap Tools, version 5.03, was utilized.The Cmap Tools is a software developed and freely distributed by the Institute for Human Machine Cognition, University of West Florida.It is used to construct conceptual maps in a graphical representation, by means of diagrams, of one or more concepts to demonstrate their relationships in the context of a determined body of knowledge (11) .

RESULTS
Data on age and gender of the elderly are shown in Table 1.The largest number of the elderly were between 60 and 65 years old.Grave (Julgamento) 16 Incurável (Julgamento) 13

Total
The results from the content analysis of data obtained in the Free Word Association Test enabled the identification of 202 terms within a total frequency of 1156.Of the 202 terms, 16 accounted for 58.8% (680) of the total frequency of terms.Table 2 shows the frequency of the 16 terms identified in the study.
Therefore, the thematic categories, cognitive, behavioral and social conditions, were established based on the concept of vulnerability in order to organize the identified terms, aiming at identifying ICNP® 2011 nursing diagnoses, as shown in Figure 1.

DISCUSSION
In this study, nursing diagnoses were identified in three thematic categories, presented below to guide the discussion of the results.
Cognitive conditions: access to information, recognizing the susceptibility and effectiveness of prevention methods Regarding the cognitive conditions, the beliefs of vulnerability to HIV/Aids of the older adults in this study are represented by the diagnostic knowledge about appropriate sexual behavior.The terms, prevention, condoms and sex, justify the identification of this diagnosis, showing that there is knowledge about protected sexual practice in order to prevent HIV infection.
For the elderly, HIV/Aids is associated with a severe and incurable disease.In this case, there is difference between being HIV-positive and having Acquired Immune Deficiency Syndrome (Aids).In a study with people over 60 years of age, it was questioned whether an Aids virus bearer always has the symptoms of the disease.Almost half the participants believed that the HIV-infected person always presents symptoms of Aids (3) .
In this study, there was no term referring to the recognition of susceptibility to HIV infection in the elderly.The terms young, prostitute and homosexual were used, but were mentioned less frequently.
Individual vulnerability assumes that any person could be vulnerable to HIV, considering that the protection available determines the degree of vulnerability.Therefore, individual vulnerability, defined as "different degrees and natures of individual and community susceptibility to infection, disease and death by HIV" (7)   should be evaluated in the context of HIV/Aids in older age, as an aspect arising from social and cultural aspects.In addition, the historical context of the Aids epidemic must be considered in view of the change of course of the epidemic, because in the beginning, in the 1980s, it primarily involved homosexuals, bisexuals, drug users and young people.
Studies on the knowledge of HIV/ Aids in older age highlight that the elderly do not think they are vulnerable to HIV infection and attribute this possibility to young people, drug users, homosexuals and prostitutes.This attitude perpetuates the belief of being a risk group for HIV infection (3,12-13)   .This perception is believed to be due to the fact that health care services are still scarce with regard to sexuality in older age and sexually transmitted diseases, resulting in knowledge of specific diseases in population groups in the elderly.
It should be noted that the approach to sexuality in older age is complex and represents a wide universe for health care professionals.The taboos and prejudices regarding sexuality of older adults generates difficulties among them to talk about HIV/Aids, and consequently impacts the understanding of their health needs by health care professionals (14)(15) .
A study about sexuality, from the perception of a group of elderly women, found that 50% reported not having access to information on sexuality; 93% said they did not receive information about sexuality during their adolescence.Most of them believed in the possibility of having a healthy sex life after 50 years of age, but they had doubts about sexual activity and wanted more information on the subject (13) .
Although the beliefs of the older adults are represented by knowledge of appropriate sexual behavior, there is also the nursing diagnosis, ability for partial protection.
Behavioral conditions: desire and ability to modify behaviors that define susceptibility In this study, the nursing diagnosis, ability for partial protection, was identified, based on the terms condom, sex, care and careless.Even though terms such as care, condoms and sex appeared, the older adults still conceived of HIV/Aids as a severe and incurable disease that requires treatment through medication.Even with advances in the treatment of Aids, HIV prevention should be a priority approach in the health care services.The improved quality of life in the elderly has been changing their sexual behavior, with more active affective relationships, deconstructing the image of older adults as asexual beings (4) .Linked to this condition, there is the increasing number of Aids cases in the elderly (6,(16)(17) as a specific group requiring health care, in the context of HIV infection.Studies indicate no perception of susceptibility to HIV infection among the elderly (3,12-13)   , which generates discussions about their ability to adopt effective protection strategies aimed at safe sexual behavior.
As for the behavior regarding HIV infection prevention, studies show incipient knowledge of the elderly about HIV transmission, and show belief in unsafe sexual practices, which leads older people not to use condoms.With regard to HIV prevention, the elderly are knowledgeable about condom use as a means of effective prevention, however, they do not use it during intercourse (3) .The elderly are knowledgeable about prevention methods for STD/Aids, but 79% of them said they had never used prevention methods during intercourse (13) .
In one study (16) in which people over 50 with HIV were asked about their past sex life, 53.2% said that they had had intercourse with more than one person before knowing that they were HIV carriers, and 90.8% reported not having used protection during sexual intercourse.The main reasons cited for the fact were trust in the partner, and lack of knowledge about the disease and the need for protection.The justification for this attitude differs between genders.Men reported not using protection mainly due to the lack of condoms at the time of the relationship, and due to not knowing about the disease and its risks.The women did not use protection because they trusted their partners.
Preventing HIV infection in women during menopause is undervalued due to a lack of information on effective HIV prevention methods (18) .There are misguided beliefs about HIV transmission.There are those who believe that a mosquito bite transmits the Aids virus (3) .Older and less educated people have little knowledge about HIV transmission, and believe that unsafe sexual practices, such as cleaning of genitals after sexual intercourse, is a way to prevent from STD (19) .
These data show social and cultural aspects about older adults' sexuality, and show that they do not consider themselves to be susceptible to acquiring STD/Aids.Older adults are therefore believed not to care about contraception, and possibly find the use of a condom during sexual intercourse unnecessary.

Social conditions: access to resources and ability to adopt protective behaviors
As regards the social conditions in this study, concepts of vulnerability to HIV/Aids of the older adults are represented by the diagnoses, fear of death, justified by the words fear and death; and hopelessness, justified by the terms prejudice, suffering, sorrow and pain.These diagnoses reveal a stigmatized belief regarding HIV/Aids among older adults.Even with proper knowledge of adequate sexual behavior and the ability for partial protection among the elderly, there is a concept of death when it comes to HIV/Aids, which shows the negative feelings of older adults regarding HIV/Aids.The elderly idealize HIV/Aids as a severe and incurable disease, and associate the fear of death and hopelessness resulting from an infection that can be prevented through the adoption of effective protective behaviors.
In a study aimed to identify health behaviors of a population 50 years old or older with HIV/Aids, a major problem encountered when considering the reduction of risks for HIV infection in these people is the inadequacy of language used, and the prejudice of believing that Aids is still restricted to the young.The study concludes that sexuality is present in the elderly and the information for the prevention of HIV/Aids in the elderly will have to take into account the deconstruction of stereotypical images of the disease at the beginning of the epidemic, as well as specific factors of the elderly population, such as difficulty changing habits and incorporating new ways of dealing with sexuality (16) .
The social representations of Aids for people living with HIV have revealed an association with the fear of death, fear of rejection, depression, hopelessness, crying, among other feelings.Daily confrontation of these subjects has a relationship with the fear of immediate death from the knowledge of HIV seropositivity.This fear is partially and gradually overcome by the pursuit of knowledge after disclosure of the diagnosis to develop self-care skills (20) .
The social component of vulnerability involves accessing information, the possibilities to conceive of them, and the power to incorporate them into practical changes in everyday life, conditions that are associated with access to material resources, social institutions such as schools and health care services, the power to influence political decisions, and the possibility of facing cultural barriers (7) .The notion of vulnerability to HIV/Aids in people at maturity or at an older age revealed a belief that AIDS in this stage of life is a consequence of libertinism and promiscuity, noting that the "HIV-positive elderly suffers more prejudice than the young".It is stated that it is "shameful to have Aids in old age".In this train of thought, this is a shameful, disappointing condition (15) .These beliefs show a prejudiced view among older people themselves, including the prevailing belief of individual responsibilities among people living with HIV through behaviors considered socially inadequate.
The lack of perception of susceptibility to HIV infection in the elderly is understood as associated with incipient knowledge on virus prevention and transmission.That impact on the lack of adoption of effective protective behaviors to HIV/Aids.The idea that Aids is a disease of young people, prostitutes, homosexuals and drug users can influence the formation of misguided beliefs about HIV prevention in the elderly and contribute to increase their vulnerability to infection.

FINAL CONSIDERATIONS
The older adults' beliefs of vulnerability to HIV/Aids are represented by the nursing diagnoses, knowledge of appropriate sexual behavior, ability for partial protection, fear of death, and hopelessness.Understanding these concepts based on the identification of nursing diagnoses enabled knowing the older adults' heath care needs and factors of vulnerability to HIV/Aids.
The study shows that older adults consider HIV/Aids to be a severe and incurable disease that requires care during sexual intercourse through condom use.They stated that a protective behavior for HIV/Aids was required, and that the disease was treated with medication.In the context of HIV/Aids, the elderly pointed to negative feelings, such as fear of death, prejudice, grief, sorrow and pain as compromising social aspects of a moral conduct.
This study had limitations regarding the identification of nursing diagnoses for behavioral conditions of the elderly in the context of HIV/Aids, because the use of the Free Word Association Test enabled identification of a few beliefs about the sexual behavior of older people in HIV prevention.
Therefore, given the results presented here, health care actions directed at sexual demands of the elderly must be planned, because sexuality is a condition indicating well-being and quality of life.Taking into consideration the epidemic of Aids within this population, assessing their knowledge about HIV transmission and prevention is required, aiming to plan health education actions and specific preventive actions in order to clarify the vulnerability factors, and to encourage the adoption of effective protective behaviors for HIV/Aids.

Figure 1 -
Figure 1 -Beliefs of vulnerability to HIV/Aids of older adults, represented by nursing diagnoses, João Pessoa, 2011

Table 1 -
Distribution of subjects according to age and gender, João Pessoa, 2011

Table 2 -
Frequency of the terms identified in the study, João Pessoa, 2011