Knowledge , beliefs , and attitudes of older women in HIV / AIDS prevention

Objective: To analyze the knowledge, religious beliefs and the adoption of preventive measures against HIV/AIDS of nonCatholic elderly women. Method: A qualitative study, carried out in religious institutions of a municipality in the state of Ceará, Northeast Brazil, with 78 elderly women. Of these, 64 were evangelicals, seven spiritualists and seven Jehovah’s Witnesses. A semi-structured interview script was used followed by thematic content analysis of participants’ responses. Results: After analyzing the empirical data, three categories were elaborated: the fi rst presented the knowledge they had about AIDS; the second, highlighted the beliefs attributed to people with HIV/AIDS; and the third, presented the preventive measures to HIV/ AIDS adopted by them. Final considerations: There were participants with knowledge gaps and failure to use preventive measures against HIV/AIDS. They suggested that religious institutions can be venues for lectures on HIV/AIDS prevention. Descriptors: Religion; Aging; Acquired Immunodefi ciency Syndrome; Elderly; Knowledge. RESUMO Objetivo: Analisar o conhecimento, as crenças religiosas e a adoção de medidas preventivas ao HIV/Aids de mulheres idosas não católicas. Método: Estudo de abordagem qualitativa, realizado em instituições religiosas de um município do estado do Ceará, Nordeste Brasileiro, com 78 mulheres idosas. Destas, 64 eram evangélicas, sete espíritas e sete Testemunhas de Jeová. Utilizou-se um roteiro de entrevista semiestruturado e a técnica de análise temática de conteúdo das respostas das participantes. Resultados: Após análise, com os dados empíricos, elaboraram-se três categorias. A primeira apresentou os saberes que elas tinham sobre aids; a segunda, evidenciou as crenças atribuídas às pessoas com HIV/Aids; e, a terceira, apresentou as medidas preventivas ao HIV/Aids adotadas por elas. Considerações fi nais: Houve participantes com lacunas de conhecimento e de uso de medidas preventivas ao vírus HIV/Aids. Elas sugeriram que as instituições religiosas podem ser locais de palestras sobre prevenção do vírus HIV/Aids. Descritores: Religião; Envelhecimento; Síndrome de Imunodefi ciência Adquirida; Idosa; Conhecimento. RESUMEN Objetivo: analizar el conocimiento, las creencias religiosas y la adopción de medidas preventivas al HIV/SIDA de mujeres mayores no católicas. Método: estudio de abordaje cualitativo, realizado en instituciones religiosas de un municipio del estado de Ceará, Nordeste Brasileño, con 78 mujeres mayores. De estas, 64 eran evangélicas, siete espíritas y siete Testigos de Jehová. Se utilizó un guion de entrevista semi estructurado y la técnica de análisis temático de contenido para analizar las respuestas de las participantes. Resultados: después del análisis, con los datos empíricos, se elaboro tres categorías. La primera presentó los conocimientos que ellas tenían sobre el SIDA; la segunda, evidenció las creencias atribuidas a las personas con HIV/SIDA y, la tercera, presentó las medidas preventivas al HIV/SIDA adoptadas por ellas. Consideraciones fi nales: hubo participantes con Knowledge, beliefs, and attitudes of older women in HIV/AIDS prevention Saberes, crenças religiosas e atitudes de mulheres idosas na prevenção ao HIV/Aids Conocimientos, creencias religiosas y actitudes de mujeres mayores en la prevención al HIV/SIDA

by elderly women", from the Graduate Program in Nursing at the Federal University of Paraíba (UFPB).It was approved by the Research Ethics Committee of the University Hospital Lauro Wanderley, UFPB, following the recommendations of Resolution 466/2012 of the National Health Council.

Type of study
This is an exploratory study with a qualitative approach (7) .

Study scenario
The study was developed in two evangelical churches, in a meeting hall of Jehovah's Witnesses and in a spiritualist house, located in a municipality in the state of Ceará, Northeast Brazil.Although this municipality has a predominantly Catholic population and is considered one of the most visited in Brazil, due to the religious motivation of devotees of Catholicism (8) , the decision to include other religious beliefs for this study was due to the fact that it allows an investigation of elderly women who have not yet been surveyed in this locus on the theme.In addition, these three beliefs are next after Catholicism in the municipal ranking, according to the IBGE 2010 census (6) .

Data source
For the definition of the sample, a calculation was made considering a sample error of 5% and a 95% confidence interval, based on the number of the female population in the third age of the research municipality (15,762) (6) .Next, the stratified proportional sampling of the three religious beliefs was defined.
Participants were selected by accessibility and convenience sampling, after analyzing the following inclusion criteria: residing in the municipality, attending the services or meetings in the religious institutions that subsidized the research and did not declare themselves to have the HIV AIDS virus.

Collection and organization of data
A semi-structured interview script was used with questions about socio-demographic data (age, schooling, religious beliefs, how long they followed the religion, civil status, time of living with the spouse, occupation, and family income) and questions about knowledge, religious beliefs and HIV/AIDS prevention practices adopted by the interviewees.In order to preserve the identity of the participants, we chose to identify them with the letter "I", from the word Interview, along with the sequential number of the interview (I 1, I 2, I 3 ...) and by self-reported religious belief at the time of the interview.
The interviews took place from June 2014 to July 2015, in a reserved place inside the religious institutions, after explaining the objectives of the research and signing the Term of Free and Informed Consent.

INTRODUCTION
The diverse concepts and opinions on AIDS were built throughout the history of the epidemic, and with disagreements, as some people believed the disease was restricted to homosexuals, drug users and sex workers.Over the years, such concepts have changed because they have witnessed contamination by the virus in other populations -for example, in the elderly (1) .
In the first 30 years of the AIDS epidemic (1981-2011), 656,620 new cases were registered in Brazil, of which 18,710 (2.85%) occurred in the elderly, and of these, 6,738 (36%) in women over 60 years of age (2) .In the first half of 2015, there were 15,181 new AIDS cases, of which 711 (4.68%) among the elderly, and of these 287 (40.36%) were female (3) .
The reasons underlying the rise of HIV/AIDS cases in the elderly are: the fact that they are not considered as a potential risk group for acquisition of the virus; empirical knowledge on the subject; the resistance to condom use; and the advent of sexually stimulating drugs.These motives confirm failures in preventive campaigns directed at the elderly, which renders them less informed and aware of how to protect themselves (1) .
Knowledge about AIDS alone is not enough to change the elderly person's behavior to ensure they adopt safe practices, but it is necessary to focus on sociocultural and religious aspects to reduce vulnerability to the HIV virus (4) .
Religious beliefs are an important theme in the life situations of the elderly, by influencing them in the construction of knowledge related to health and in the adoption of behavioral measures, including body care (5) .
Brazil, according to the 2010 census of the Brazilian Institute of Geography and Statistics (I BGE), presents a great diversity of religious beliefs.The numbers showed that most of the older women reported following Catholicism (8,075,814), and the others were divided into: evangelicals (2,354,984), spiritualists (323,871) and Jehovah's Witnesses (97,649) (6) .
When addressing the issue of vulnerability to HIV/AIDS in elderly women, it is relevant to develop research that seeks to answer the following question: Do their knowledge and religious beliefs influence the adoption of preventive measures to this virus?
Research with elderly Catholic women is common, however, it is also necessary to determine and divulge what the followers of other religious beliefs know about the subject and how they protect themselves.Thus, the present research aims to analyze knowledge, religious beliefs and the adoption of preventive measures to HIV/AIDS of non-Catholic elderly women.

METHOD Ethical aspects
The study originates from the PhD thesis entitled "Beliefs, Practices and Social Representations on HIV/AIDS constructed Milena Silva Costa E-mail: milenascosta2011@hotmail.com CORRESPONDING AUTHOR lagunas de conocimiento y de uso de medidas preventivas al virus HIV/SIDA.Ellas sugirieron que las instituciones religiosas pueden ser locales de conferencias sobre prevención del virus HIV/SIDA.Descriptores: Religión; Envejecimiento; Síndrome de Inmunodeficiencia Adquirida; Mayor; Conocimiento.

Data analysis
The sociodemographic data of the participants were entered in the Statistical Package for the Social Sciences (SPSS), version 19.0, for descriptive analysis.The answers to the open questions were categorized according to thematic content analysis, following the steps of pre-analysis, material exploration, treatment of results and interpretation (9) .

RESULTS
A total of 78 elderly women participated in the study; of these, 64 were evangelicals, seven spiritualists and seven Jehovah's Witnesses.In this research, a descriptive analysis of the sentences was performed, extracting the messages and information pertinent to the subject in question.As a result, three categories were created with their respective context units (9) : knowledge about AIDS; opinions about the disease; and preventive measures against HIV/AIDS.

Characterization of the sociodemographic profile of elderly women
Table 1 shows the sociodemographic data of the elderly women investigated in relation to age, schooling, religious beliefs, time practicing their religious beliefs, marital status, time living with spouse, occupation and family income.

Knowledge about AIDS
The category AIDS knowledge showed that 28.2% of the context units extracted from the interviewees related AIDS as a disease that compromises the immune system and is caused by viruses.
[...] it is a disease that lowers the defense rates of the body... when the virus ends the immune system, the person becomes sick, then it is one step to die AIDS was also associated with religious belief in 6.4% of the context units, because it was considered a disease that causes many problems.They stated that only God can save an individual infected with the virus.The most common forms of transmission by the population were reported correctly by 74.3% of respondents, who said that the virus is transmitted by blood, sexual intercourse and vertical transmission.This knowledge did not differ among elderly women of different religious beliefs.Note: * The minimum wage in force during the study period was R$ 788.00.However, 11.5% of the statements had knowledge gaps on HIV transmission media, since they affirmed that it could occur through kissing, toilet seats, sweating, using utensils and airways.Limitations in knowledge on the subject were expressed in 65.3% of the context units, which may configure a type of vulnerability of these women to the HIV virus.Opinions about the disease AIDS was recognized by the Jehovah's Witnesses and evangelicals interviewed as a disease that causes prejudice and pity.The people were infected by carelessness or fatality.They mentioned that it is a difficult situation to face, because it is rooted in stigma.They admitted that AIDS requires care, especially when it is at the onset of the disease; it is necessary to seek a doctor to initiate early treatment and to obtain a longer life; and emphasized, as a form of care, preventive measures to avoid transmissibility.AIDS was seen by 41.3% of respondents as a disease that does not affect the religious beliefs of the person affected or that arouses faith in those who, before the disease, did not seek it.With pain and suffering, these people tend to seek spiritual support, approaching God, since they cannot always find that support among the people in their lives.
[...] I think it's a moment when she turns to God. [...] I saw this a lot in people who died, who were my friends and lived in a new spirit [...] God came to the person and it was in him that they clung and could see that God is everything in life, that they could come to him [...] it is not because they had the disease, that God had abandoned, on the contrary, that was the moment of their reunion with God [...] (I 26 -spiritualist)

[...] the person who discovers that he or she has AIDS has their religion altered, because everyone suffers changes in religious beliefs [...] we grow through pain and love [...] they say that pain brings us closer to God [...]. (I 37 -spiritualist) [...] who has AIDS is very fragile, but will not shake his religion [...] he has to be very firm in religion [...]. (I 76 -evangelical)
On the contrary, 23.1% of the participants reported that AIDS can also affect religious beliefs, because of despair, discrimination, revolt, fear of death and other factors that lead to a reduction in faith and leaves the individual disbelieving in God and their beliefs.

Preventive measures against HIV/AIDS
The media were the first cited as preventive measures against the HIV/AIDS virus.At the time of the interviews, they mentioned television, radio, surveys, magazines, newspapers, lectures, pamphlets and dialogues as sources of information on the subject.All Jehovah's Witness participants cited the Awake!magazine as a vehicle for disseminating this information, as well as being a religious magazine.Health professionals, friends, neighbors and relatives were also remembered.The prevention methods were cited by 52.6% of the participants, who emphasized the specific use of nail clippers when searching for the manicure, disposable material during the blood test, conducting exams and using the condom.Jehovah's Witnesses stressed that they do not accept blood transfusions because they follow religious dogma.Suggestions for preventive measures through religious beliefs were stated by 79.5% of respondents who said that if all churches promoted lectures and guidance for young people and if people were to strictly follow this guidance from religious beliefs about HIV/AIDS prevention, they would not be infected.They added that faith, prayer, love and reading would also help as a preventive measure.Participants were encouraged to respond whether or not they received guidance from religious institutions on the subject.As a result, 61.5% said they were told not to commit adultery, prostitution and fornication, refrain from receiving blood transfusions, use of condoms (guidance in the evangelical church), homosexuality and use disposable materials.
[...] my religion says that in order to prevent AIDS, it is important to avoid sexual relations outside marriage, homosexuality and to refrain from receiving transfusions.(I 33 -Jehovah's Witness) [...] we have four points of doctrine, which we follow in our religion, to prevent AIDS: the male with male is abominable in the kingdom of God; the prohibition of adultery, prostitution and fornication.(I 58 -evangelical) [...] in the church, they advise to be careful during manicure, using a condom when you have relations, not using the same syringe by two people [...].(I 63 -evangelical) The measures adopted by the elderly women for HIV/AIDS prevention were through [...] a lot of information in the media, television, magazines, newspapers [

DISCUSSION
Most of the elderly women who participated in the study had low levels of schooling and knowledge gaps on the subject of HIV/AIDS, but some were able to cite the definition of the disease and describe the forms of transmission.
The definition as expressed by them was in accordance with what the Brazilian Ministry of Health says about AIDS, i.e. it considered to be a disease that causes severe dysfunction of the immune system of the individual infected by the HIV virus, which is transmitted through direct contact and/or exchange of blood and/or body fluids from an infected person to an uninfected person, unprotected sexual intercourse, intentional sharing of needles or occupational accidents, contaminated blood transfusion and vertical transmission (10) .
The results drew attention to incorrect forms of transmission, since reports have stated that the HIV virus can be transmitted by the toilet seat, using cutlery from infected people, drinks and airways.These media are not vehicles for the virus, although authors (10) have reported in a study that alcoholic beverages may be indirectly associated with sexual transmission of the HIV virus, since the person under the effect of this drug is less likely to remember the use of preventive measures.
Regarding the definition of AIDS associated with belief, only 6.4% of the elderly women interconnected the theme and attributed responsibility to God for the improvement or healing of the person affected by the disease.As religious faith is meaningful, most Brazilians believe in the action of the sacred for the prevention and cure of diseases.These are the reasons why people seek religious help (11) .
Within this context, the subject was explored further and a second category emerged.Opinions on AIDS have revealed that, even after over 30 years since the discovery of the disease in Brazil, it is still possible to observe people discriminating against the HIV positive individuals.This may be due to the way in which the epidemic was presented to the country and to the prejudices that arose from their beliefs.The history of the disease reveals that at the onset, while governmental and nongovernmental organizations were trying to find solutions to the epidemic, religious institutions maintained themselves distant from the events, thus allowing diverse beliefs to be constructed (12) .
AIDS has also been mentioned as a disease that awakens or does not alter the religious beliefs of those who are sick, bringing them closer to God and to religious dogma.An integrative review pointed out that older people as well as others of different ages are expected to seek strength in God to face problems, frustrations and difficulties at these times (12) .
The third category evaluated HIV/AIDS prevention measures by the interviewees.They immediately highlighted the sources of information used by young people and for their own benefit.
Information regarding AIDS has been disseminated by the media and other means of communication, especially in times of greater risk of transmission; however, this diffusion focuses on the young and disregards the elderly.In addition, cultural, social, psychological and religious factors that influence the process of receiving information from people, as well as the form of their behavior are ignored.As a result, there has been an increase in elderly, married and heterosexual women infected by the HIV virus through their spouse (13) .Thus, it is essential that sexual education in the third age be implemented to enable positive attitudes, improve sexual and affective relations, and the quality of life among this public (12) .
Respondents described the forms of HIV/AIDS prevention adopted by them, and among those cited, elderly Jehovah's Witnesses emphasized that they refuse blood transfusions.Nowadays, blood transfusions are rarely a form of HIV virus transmission, nevertheless it is emphasized that the religious understanding of Jehovah's Witnesses does not absolutely prohibit the use of blood components, such as albumin, immunoglobulins, and preparations for hemophiliacs, as well as hemodialysis, provided blood-free primer solutions are used.For this, each person has the free will to decide whether or not to accept this type of treatment (14) .The other preventive forms cited are in accordance with the recommendations in the literature (15) .
Those interviewed who denied the adoption of preventive measures may be exposed to the HIV/AIDS virus if they are at risk.The underestimation of personal risk of contagion and beliefs about AIDS in the elderly are considered to be aspects that increase vulnerability, especially when this perception is associated with insufficient information about the subject among this group (16) .
In this study, the religious institutions were suggested by the interviewees to be a space to minimize the vulnerability of people, through the guidance of religious dogmas and lectures.An example of this proposal was found in a study carried out in Jamaica, in which older people who reported practicing their religion and respecting established dogmas presented safer sexual practices (12) .
The guidelines received in Brazilian religious institutions restrict family issues, marriage and fidelity, leaving sexuality limited to procreation.There are religious leaders who view sex in the third age as permissive.These traditions need to be reviewed and replaced by discussions that break the taboos of sexuality in the elderly.
As in Brazil, the call for religious institutions to take a leading role against the HIV virus has also been reinforced in Asian countries and the United States of America (17) .
AIDS has brought to religious institutions the challenge of inserting this theme into dialogues among their congregation, since they must realize that many people affected by the disease suffer prejudice and hope to find in the church a place where their rights are respected.Likewise it is important that religious leaders offer guidance so that their followers know how to protect themselves (12) .
Consequently, religious leaders should consider that the sexuality of the elderly person is a relevant topic; hence they need to adapt the religious and ethical criteria of the past to a new reality through information that enables such audiences to develop safe-sex practices (13) .

Limitations of the study
The limitations of the study are related to the fact that the investigation occurred in only one municipality, which does not mean that the reality found can be extrapolated to other Brazilian municipalities; as well as to the fact that the research did not cover all the religious beliefs present in Brazil.
Contributions to the area of nursing, health or public policy The objective of this study was to contribute to the development of strategies aimed at HIV / AIDS prevention in elderly women, to increase the knowledge of nursing professionals and other health professionals about the subject matter, as well as to provide knowledge to the elderly and society on elderly individuals' vulnerability to AIDS.

FINAL CONSIDERATIONS
It is considered that there were elderly women in this study who presented limited knowledge on the definition of AIDS and on the means of transmitting the HIV virus, as well as difficulties in relating the theme to their religious beliefs.The preventive measures cited were the care with objects capable of causing cuts or puncture wounds, seeking information, examination and of condoms.Religious institutions were suggested as venues to offer lectures on prevention and reduction of people's vulnerability to HIV/AIDS.
It is hoped that the results of the research may help reflections of the elderly, health professionals and society to enable changes regarding the sexuality of people over 60 years of age.
[...] there are people who have prejudice to get close to those who have AIDS, because they die of fear of catching it too [...].(I 2 -evangelical) [...] AIDS is a sexually transmitted disease caused by the HIV virus, which already has medication for it, which are the cocktails and the person can take [...] the person can have HIV and live many years [...].(I 27 -spiritualist) [...] AIDS has no cure, it is a problem, but it has treatment [...] it is terrible that disease ... God alone can save [...].(I 40 -evangelical) [...] AIDS has treatment, when God wants [...].(I 70 -evangelical) [...] in the kiss, toilet seat, sweat, using a plate that the person ate from [...].(I 11 -evangelical) [...] must be on the toilet seat and in the drink [...].(I 13 -evangelical) [...] you can catch it when you sit in the place where someone with AIDS sat and when you talk too [...] (I 49 -evangelical) [...] I do not know what AIDS is, but I know there are people who treat it [...].(I 65 -evangelical) [...] they say that AIDS is a serious disease that has no treatment, but I cannot explain [...].(I 72 -evangelical) In summary, the category showed that for the respondents, AIDS is a sexually transmitted disease caused by the HIV virus [...], which lowers the rates of body defenses and [...] only God can save [...] is transmitted by blood, sexual intercourse, occupational accident and in the vein, through contaminated syringe [...] in addition to other forms cited.Some believed that [...] you can catch it when you sit in the place of those who have AIDS, and when you talk too [...].There were also those who presented limitations in their knowledge on the subject when they expressed that: [...] I do not know what AIDS is, but I know that there are people who have treatment [...].
[...] it is difficult to face prejudice, even though many people are enlightened [...].(I 22 -Jehovah's Witness) [...] I feel sorry for the person who contracted AIDS, because it was a fatality, lack of care or vanity [...].(I 71 -evangelical) [...] I watch on television and there is a radio show that the doctor explains what AIDS is [...].(I 4 -evangelical) [...] I research, because I'm doing work on this topic [...] I have more than 30 articles saved in my computer [...] I always liked this theme because I'm divorced, I've already got some boyfriends that I was afraid to pass on diseases, so I like to read how prevention should be [...].(I 31 -spiritualist) [...] we have a lot of information; in the media, television, magazines, newspapers [...] we have a worldwide circulation magazine, called the Awake!magazine, which, besides being biblical, is scientific [...] it explains the guidelines on how to prevent AIDS [...].(I 34 -Jehovah's Witness) [...] I talk to my grandson, watch lectures and read about the subject [...].(I 53 -evangelical) [...] the little that I know about AIDS, I learned at the health centers and from the health agent [...].(I 60 -evangelical) [...] I take my nail clippers when I go to the manicure, I observe whether the material is disposable when I go for a blood test and as for sexual relations, I trust my husband, I would put my hand in the fire for him [...].(I 9 -evangelical) [...] Jehovah's witnesses do not accept blood transfusion, I have never had a problem with my husband, I always do my exams and I have no relation with other men [...].(I 23 -Jehovah's Witness) [...] I've had a partner for nine years, and when we have sex, we use a condom [...].(I 27 -spiritualist) [...] it is caused by a virus, which is transmitted by blood, sexual intercourse, occupational accident and in the vein, through a contaminated syringe [...] if the person has responsibility and information, they will not get it or put others at risk, because he will prevent himself ... I knew a couple that he got it from a mistress and then passed on to his wife [...].(I 18 -evangelical) [...] it is transmitted by blood, syringe used by others, relationship, manicure material, if it is not sterilized and kisses, if the mucosa is injured [...].(I 2 -evangelical)

Table 1 -
Distribution of elderly women interviewed according to sociodemographic variables, in a municipality of Ceará, Northeast, Brazil, 2015 [...] if it is at the beginning and God willing, that is to say that she will have one more chance, but if she does not go to the doctor and is not careful, it ends there [...].(I 5 -evangelical) [...] I would advise her to get out of this problem, to go to the doctor and tell her what was happening and not pass it on to others [...].(I 15 -evangelical) Only in 11.5% of the contextual units the interviewees' statement showed they have no prejudice against people who have the HIV/AIDS virus.They considered that such individuals can have a normal life and should not fear prejudice.[...] who has AIDS is like any other, but had the misfortune to contract this disease [...] I would treat normally if I knew someone with AIDS ... I would be very disappointed with myself if I acted in a contrary way [...].(I 31 -spiritualist) [...] who has AIDS, is a normal person, does not need to be afraid, he is neither better nor worse because he caught AIDS [...].(I 50 -evangelical) discriminated against [...].(I 35 -Jehovah's Witness) [...] people with AIDS have their religion affected, because they know that they have a problem that has no cure [...] there are people who are so weak that they even think of abandoning God, but, in fact, they should feel the opposite [...].(I 74 -evangelical) In summary, the Opinions on the disease category demonstrated that the elderly women believed that [...] it is difficult to face prejudice, even though many people are enlightened [...].And that [...] if it is in the beginning and God willing, that means that she will have one more chance, but if she does not go to the doctor and is not careful, it ends there [...].Some elderly women did not show any prejudice because they said that [...] those who have AIDS are normal people, they do not need to be afraid, they are neither better nor worse because they caught AIDS [...].AIDS was seen as a disease that awakens religious beliefs, because it is [...] a moment when one turns to God [...].However, others said that [...] the person with AIDS has their religion affected because they feel very discriminated against [...].
[...] if you follow what religion guides you, you would never get this disease.(I 16 -Jehovah's Witness) [...] religion can help in the prevention of AIDS if there is a lecture in the church, if the pastor or brothers talk about prevention [...] in every church they can speak, the priests, pastors, the schools, everyone can say that a person should take preventive measures ... any religion can give advice, regardless of whether it is Catholic or evangelical [...].(I 20 -evangelical) ...]; they note [...] whether the material is disposable when going for blood tests; use of condoms [...] and Jehovah's Witnesses do not accept blood transfusion [...].They suggested that if a person [...] follows what religion teaches, he would never catch this disease [...].They said that [...] in the church, they advise to be careful during manicure, using a condom when they have relationships, not using the same syringe by two people [...].