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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.4 São Paulo Aug. 2012
Renata Holanda Dutra dos AnjosI; José Augusto de Souza SilvaII; Luciane Ferreira do ValIII; Laura Alarcon RinconIV; Lucia Yasuko Izumi NichiataV
in Nursing from the University of São Paulo School of Nursing. São
Paulo, SP, Brazil. firstname.lastname@example.org
IIDegree in Nursing from the University of São Paulo School of Nursing. São Paulo, SP, Brazil. email@example.com
IIIDoctoral Student of the Post-graduate Nursing Program of the Collective Health Nursing Department of the University of São Paulo School of Nursing. São Paulo, SP, Brazil. firstname.lastname@example.org
IVDegree in Nursing from the National University of Colômbia School of Nursing. Bogotá, Colômbia. email@example.com
VRegistered Nurse. PhD. Associate Professor of the Collective Health Nursing Department of the University of São Paulo School of Nursing. São Paulo, SP, Brazil. firstname.lastname@example.org
The objective of this study was to comparatively analyze male and female adolescents' vulnerability to HIV/AIDS, based on their knowledge, values and practices. This is an exploratory-descriptive study, performed using a quantitative approach. The students answered a questionnaire from which relevant questions were selected for the analysis. The participants were 207 adolescents, 43.5% male and 56.5% female. Most adolescents report having initiated sexual activities. It was observed that the participants have knowledge deficits regarding HIV transmission and safe sexual practices. Although they report knowing about condom use as a method of protection against HIV, they do not always use them. It was observed that there are values connected to the representations of gender, but it is noticed there is an evolution regarding the autonomy and power of the girls' negotiation regarding condom use.
Descriptors: Acquired Immunodeficiency Syndrome; HIV; Adolescent; Health vulnerability; Gender identity
The AIDS epidemic remains a major health challenge worldwide. Data from the UNAIDS show that currently there are approximately 33 million people living with HIV in the world and that in 2009 2.9 million new cases of the disease were detected(1). Information on the occurrence of Sexually Transmitted Diseases (STDs) and HIV/AIDS in Brazil are presented and analyzed annually in the Epidemiological Bulletin. In its latest version, released in 2010, focus is given to cases of AIDS in young people of between 13 and 24 years of age, who accounted for 11.3% of the cases registered in the country between 1980 and June 2010(2). During this period there were 492,581 AIDS cases reported in Brazil. In 2009, 20,832 cases were reported, with 13,159 in males and 7,671 in females, and in 2010, until June, there were 5,845 cases with 3,718 in males and 2127 in females. It is observed that in the last two years the ratio of the genders was 1.7:1 (17 men for every 10 women)(2). Among young people of 13 to 24 years of age 3,398 cases of AIDS were reported in 2009, with 1,875 in males and 1,523 in females, and in 2010, until June, 1,317 cases, with 745 in males and 572 in females. The gender ratio was 1.2:1 (12 men for every 10 women) and 1.3:1 (13 men for every 10 women) in the years 2009 and 2010 respectively. The highest proportion of cases of the disease in this age group is attributed to the sexual exposure category, accounting for 73.8% of the cases in males and 94.0% in females, in 2009(2).
The concept of vulnerability, adopted in the present study seeks to comprehend the individual, collective and contextual aspects that make people susceptible to HIV infection and AIDS. The analysis of vulnerability seeks to integrate three interdependent axes, which are the individual, social, and programmatic dimensions. In the individual dimension, the values, interests, beliefs, desires, knowledge, attitudes, and behavior, which impact in the exposure to or prevention of HIV/AIDS for the individual, are considered. In the social dimension, it is sought to contextualize, material, cultural, political, and moral factors, which affect individual vulnerability. In the programmatic dimension, how the health, education, social welfare and cultural institutions provide the social resources that people need to protect themselves from HIV infection and AIDS is analyzed(3).
Adolescence is a period of intense physical, psychological and social changes, in which the individual undergoes personal and interpersonal conflicts. This phase of life, in which values and concepts are consolidated, is influenced by the cultures of family, media, friends and society as a whole, which will permeate the persons attitudes in future life(4-5). In this stage of life, the exercise of sexuality starts to occupy a very important space(6) and many adolescents become sexually active, which makes them vulnerable to suffer health problems. Regarding sex in adolescence, many issues are not properly approached, indicating a spontaneous attitude regarding sexuality that disfavors conversation and prior preparation(7). The vulnerability of adolescents to STDs is the result of the interaction of individual factors with the social factors in which they are involved, with them becoming more or less vulnerable depending on their ability to critically reinterpret social messages of danger(5). It is therefore necessary to encourage them to think critically about the reality in which they live to be able to exercise autonomy in their choices, thus reducing their vulnerability(4).
Several studies show that there are differences in the behavior of male and female adolescents regarding sexuality, and that a common point is the greater attribution of responsibility to women. The boys show interest earlier regarding the initiation of their sexual lives and are more uninhibited and inconsequential in relation to STDs and pregnancy. They are under pressure from parents and friends to begin their sexual lives, to prove their masculinity(5). The girls take a role of silence and conformity with the desire of the partner, presenting a disadvantage when negotiating condom use. In addition, they trust in a steady partner, relinquishing the use of condoms during sex because they believe in their partner's fidelity, arguing that to request the use of a condom may indicate a lack of trust or even betrayal by them(5).
It is interesting to note that social representations are amenable to change, which is often necessary since many established patterns are detrimental to the way of life of the men and the women. These patterns of masculinity and femininity are treated as natural, without thinking critically about them, which can impact negatively on health, as both are vulnerable to STDs. For the woman, vulnerability increases due to the lack of negotiating power and control over the relationship, for the man, it increases due to social pressure to always be ready for sex, assuming a role of being without control over their impulses. The discussion of these issues assumes an emancipatory character in that it questions the internal logic of the construction of the difference, suggests a more critical posture faced with the social roles assigned to men and women, and motivates adolescents to become agents of change in the environment in which they live, recognizing the place of women in society and reclaiming their rights. We understand that, when we discuss gender issues, we have already begun to transform them(4).
The aim of this study was to analyze the vulnerability to HIV/AIDS in female and male, adolescent, high school students from two public schools in Peruíbe/SP, according to their knowledge, values and practices.
This quantitative, exploratory, descriptive study is an integral part of the study Vulnerability of High School Youths to HIV/AIDS: What Changed in Ten Years?, which aims to compare knowledge and protective practices taken against HIV, reported by students from two public high schools in Peruíbe/SP, where the same approach was carried out in 1999 and 2010(8). The study participants were students enrolled in two state public schools in Peruíbe, SP, Brazil. In the study conducted in 1999, 2,219 students were enrolled in the two schools. Probability sampling was used, resulting in 360 students, 15% of the total possible population.
In the study conducted in 2010, 1,512 students were enrolled in the two schools. To define the sample of students, a proportion based on the knowledge about sex of the high school students from the first study (67%) was used, considering a margin of error of 0.05%, which resulted in a sample size of 323 students. However, 226 students actively participated in the study. The loss of 30% occurred because, despite the receptivity of the students and the schools, some students did not bring the signed Terms of Free Prior Informed Consent (TFPIC), others refused to receive the TFPIC to collect the signature of the parent or guardian, and other missed the delivery date of the TFPIC or the day of data collection.
In accordance with Resolution 196/96 (Brazil, 1998), of the National Health Council, the project was submitted to the Research Ethics Committee of the University of São Paulo School of Nursing (EEUSP) and was approved under protocol No. 871/2009. The TFPIC was delivered the day before for the under 18 to request the signature of the parent or guardian and the next day it was exchanged for the questionnaire with the researchers. All the students answered the questionnaire and then returned it immediately.
In 2010, the self-applied anonymous questionnaire used in 1999(8) was applied. Composed of two parts, the first inquires about the general socioeconomic characteristics of students and the second addresses issues related to the knowledge, beliefs, values, attitudes and practices related to sexuality and vulnerability to HIV, totaling 51 questions. The questionnaire contains closed questions, some of which are multiple choice, scored on a Likert type scale. A total of 226 students responded to the questionnaires, with 99 (43.8%) males and 127 (56.2%) females, aged between 13 and 30 years. However, for this, study students were selected who were aged up to 19 years, totaling 207 individuals, of which 43.5% were males and 56.5% were females. This selection occurred because this age group represents the young people at the peak of their biopsychosocial transformations and in a phase of formation of concepts that accompany and influence the rest of their lives(9).
In the present study, not all the matters contained in the questionnaire were analyzed, choosing to select only those that were most relevant to the topic. The answers to the questions were entered in to a Microsoft Excel database and analyzed using the Epi Info statistical program. The data is presented in a comparative form and described by gender. For comparison of the responses by the adolescent males and females the Chi-square, Likelihood Ratio and Fisher statistical tests were used. For a conventional 0.05 level of significance, values of p>0.05 showed there was no statistically significant differences between the variables, and values of p<0.05 show that there was significant differences between the variables. Before the analysis, the missing data were removed for each question, and therefore each has a different total of respondents.
The participants were 207 adolescents, 90 male (43.5%) and 107 females (56.5%) aged between 13 and 19 years. According to the boys, 60.7% said they have had their first sexual intercourse by the time the study was conducted, the mean age of first sexual intercourse was 14.53 years, with nine years the minimum age and 17 years the maximum. Among the girls, 57.3% had had their first sexual intercourse, with the first sexual intercourse occurring at the mean age of 14.70 years, 12 years being the minimum age and 17 years the maximum. The differences between the sexes were not statistically significant. In relation to knowledge about AIDS, there was a higher percentage of girls (44.3%) than boys (40.2%) who evaluated that they knew little or nothing about the matter, without statistical significance differences between the sexes.
Table 1 shows that the vast majority of adolescents of both sexes agree that it is possible to acquire HIV through sexual intercourse with a partner and from the sharing of contaminated needles and syringes by injecting drug users. There was a higher percentage of girls (71.6%) than boys (54.7%) that agreed that the transmission of the virus from an infected mother to her child occurs, with a statistically significant difference between the sexes. A percentage of 58.5% of the adolescents agreed that a person with AIDS can look healthy, and 40% of them agreed that HIV transmission does not occur from bus or toilet seats. Table 1 also shows that the majority of the adolescents disagreed with the idea that it is possible to acquire HIV from studying with an infected person. There were 72.2% of the boys and 80.2% of the girls who disagreed with the idea that you can acquire the virus from shaking hands, hugging or kissing the cheek of an infected person. A low proportion of adolescents disagreed with the misconceptions about HIV transmission, such as through: the use of public swimming pools (51.7%), insect bites (49.3%), the use of toilets, cups, eating utensils or towels after use by carrier (39.6%). There was also a low proportion of adolescents who disagreed that it is possible to recognize a person with AIDS by their appearance (59.4%). It is possible that the majority of the adolescents, with a higher proportion of females, had correct knowledge about the ways that HIV is actually transmitted. However, in relation to the myths about the transmission and the physical stereotypes of a person with AIDS, the males presented more doubts.
The majority of the adolescents of both sexes believed that AIDS is a dangerous disease (95.1%) and that everyone is at risk of acquiring the disease (82.5%). They also believed in the use of condoms as a safe means for disease prevention (95.2%). Most of them (89.3%) disagreed that the only way to avoid AIDS is to have faith in God. There was a higher percentage of girls (86.1%) than boys (73.3%) who disagreed with the idea that having good luck avoids AIDS, and there was also a higher percentage of girls (74.1%) than boys (60.0%) that disagreed that there is no point doing anything as it is the destiny of that person to have AIDS. It can be seen that the adolescent males believe more in luck and destiny as decisive factors for acquiring HIV or not.
Table 2 shows that the vast majority of the adolescents considered the practice of vaginal sex without a condom unsafe. The practice of anal sex without a condom was considered unsafe by the majority, but caused doubts in 20.5% of the adolescents and oral sex without a condom was also considered unsafe by the majority, but caused doubts in 27.8 % of adolescents.
In Table 3, we can see that there was a higher percentage of girls (99.1%) than boys (88.9%) who believed that they can catch AIDS if they do not use condoms, and there was also a higher percentage of girls (82.9%) than boys (67.8%) who disagreed with the fact that choosing partners carefully avoids AIDS, with statistically significant differences between the sexes. For both sexes, the percentage fell (75.0%) with regards to the possibility of catching AIDS if they did not use condoms with their partner, which highlights that, for adolescents in general, confidence in the partner is used in place of condoms as a mode of prevention.
Regarding the self-assessment of the risk of acquiring HIV, there was a higher percentage of boys (57.0%) than girls (46.1%) who believed they have some risk, while there was a higher percentage of girls (31.3%) than boys (26.7%) who believe that they had no risk. A total of 16.3% of the boys and 22.6% of the girls stated that they did not know if they had a risk of acquiring the virus, and these differences were not statistically significant (p=0.288). It was found that over half of the adolescents perceived themselves at risk for contracting the disease, with a higher percentage of boys having this perception.
Regarding the correct use of condoms, there was a higher percentage of boys (73.3%) than girls (56.4%) who said they knew how to do this, which is a statistically significant difference (p=0.012). Concerning the frequency of condom use, a higher percentage of boys (66.7%) than girls (52.4%) said they use one in all their sexual relations. A total of 29.4% of the boys and 42.9% of the girls stated that they use one in some relations and 3.9% of boys and 4.8% of girls claimed to never have used a condom, with no statistically significant differences between the sexes (p=0.297). The percentage of girls (19.8%) was significantly higher than the percentage of boys (4.7%) who stated that they would be embarrassed to carry a condom in their pocket or purse. Furthermore, there was a higher percentage of girls (48.5%) than boys (21.7%) who stated that they would be embarrassed to ask to borrow a condom from a friend, these differences were statistically significant (p<0.001). Conversely, there was a higher percentage of boys (14.1%) than girls (1.8%) who stated that they would be embarrassed to say to a steady partner that they did not want to have sex without a condom, which is a statistically significant difference (p<0.001). In relation to the fear of becoming infected from unprotected sexual intercourse, a higher percentage of girls (81.5%) than boys (69.9%) said they would have that feeling, with no statistically significant differences between the sexes (p=0.059). Fear can be associated with the self-perception of vulnerability and exposure to risk situations for acquiring the disease, which this study found to a lesser extent in the males.
In Table 4, it can be seen that the vast majority of the adolescents consider the fidelity of men and women important in the prevention of AIDS. The emphasis on virginity is greater on behalf of the boys, with both them and the girls placing more value on the virginity of the woman than on that of the man. The representations of the woman as chaste and pure and the man as strong and virile influence the values of the adolescents, which give greater emphasis to female virginity.
A study investigated the issue of age and condom use in the first sexual intercourse, noting that there is a drop in condom use in individuals who started their sexual life at 14 years of age, and that this decrease was even greater in women(10). The interest in this issue is due to the association between the behavior at the first sexual intercourse and the behavioral patterns that will be followed for the entire life. Therefore, if there is a tendency to not use condoms when the age at first sexual intercourse is low, this behavior, which increases vulnerability to HIV/AIDS, needs to be studied. In the present study it was observed that the mean initiation of the sexual life was very close to 14 years of age for both sexes, which is the maximum age the cited author deemed to be negatively associated with condom use.
Data presented in the Survey of Knowledge, Attitudes and Practices in the Brazilian Population (PCAP)(11), performed with individuals 15-64 years of age, with the entire national territory represented, in 2008 and published by the Ministry of Health in 2011, show that there is a higher percentage of men (36.9%) than women (17%) who had first intercourse before 15 years of age, indicating a pattern of underage males at the first sexual intercourse. This result is further noted in two studies(10,12), with the latter finding a mean age at first intercourse for adolescent males of 13.7 years, compared to the mean of the female adolescents of 15.1 years. The present study did not show the same pattern, since the mean ages found among the girls and boys were very close.
In relation to knowledge about AIDS, the degree of knowledge was not sufficient for a person to adopt protective behavior, with this lack contributing to increased vulnerability to HIV/AIDS(13). The analysis of the indicators of knowledge by gender carried out in the PCAP(11) revealed that the men had a higher level of correct knowledge about modes of transmission of HIV than the women. However, in the present study, it was found that the female adolescents had greater knowledge about HIV transmission and other aspects of AIDS than the males. Thus, it can be inferred that the distribution between the genders of knowledge on the subject in the age group from 13 to 19 years is different from the distribution in a wider age range (15 to 64 years).
The literature shows that knowledge about available contraceptive methods is high, however, although this knowledge has provided a considerable increase in adherence to these methods, their use does not always occur regularly or in the most suitable way(14). The degree of knowledge of AIDS prevention measures revealed by the adolescents interviewed would be sufficient to prevent HIV infection, however, some attitudes and some behavior denote inconsistency between the discourse and practice of prevention, making it possible to engage in unprotected sexual intercourse(15) . This difference between knowledge and practice regarding the use of condoms is confirmed in the present study. The transformation of knowledge about HIV/AIDS into the adoption of protective practices depends not only on informative issues, but also on the comprehension and ability to assimilate this information, which are influenced by gender, social class, race and other social issues(13).
The differences found in this study regarding knowledge of the correct use of male condoms, which was most often found in the male adolescents, may be linked to the fact that male condom use is in practice for the use of men, who eventually dominate the techniques of use. It is also possible that for this reason the girls delegate the responsibility of knowing how to use condoms to their partners. Furthermore, it was observed that condom use was more frequent among the boys, which may be associated with many factors, such as: the greater number of partners, the greater knowledge of the technique of use or greater control over the way that the sexual intercourse will be conducted. Another study presented significant differences between men and women regarding the perception of risk for HIV/AIDS(13), which was confirmed in this study. Fear of AIDS was present in the population studied, and this feeling was higher among the students who recognized that they were not protecting themselves from the disease and among those who reported not knowing whether they do or not, than among those who claimed to protect themselves(16). In the present study, the fear of catching AIDS through unprotected sexual intercourse was also found in the majority of the adolescents, with this feeling presented more by the girls.
The inequality of power in the relationships between men and women is one reason for the difficulty that both have to discuss safe ways to exercise sexuality(6,17), as it is often the man who decides how and when sexual intercourse will be performed. However, in the present study, it was found that the majority of the adolescents reported having no embarrassment in asking their partner to use condoms or to refuse to have sex if they did not want to use one, demonstrating that they have greater negotiating power and greater autonomy in the relationship. The higher percentage of female adolescents than males that revealed that they would be embarrassed to carry condoms or to ask to borrow one from a friend may be associated with the fear they have of being seen as interested in sex, which would go against the passive role of the woman expected by society. Also, the fact of finding a higher frequency of male adolescents who indicated that they would be embarrassed to tell a steady partner that they do not want to have sex without a condom can be associated with the stereotype that the man should always be ready for sex and not refuse to have sex, and also the concern that the girlfriend might question their fidelity if they should suggest condom use.
The most frequent reasons reported by the girls for not using condoms were trust in the partner, the partner does not like condoms, they reduce the pleasure and they break the mood of sex. The trust in the partner is probably related to the type of bond and the emotional involvement at the moment of the sexual act(6). One study demonstrates that the condom is replaced by trust, resorting to the pill to avoid pregnancy and the acquisition of a disease ceasing to be an issue(7). The option for other contraceptive methods when the relationship becomes stable can also be observed in another study(18). This is confirmed in the present study where the adolescents revealed that they would have less fear of catching HIV having unprotected intercourse with a steady partner than having unprotected intercourse in general. This also appeared among the girls, who declared that they no longer ask the partner to use condoms because they trust him.
The pact of fidelity in steady relationships, which brings confidence in the partner, was highlighted by another study(6). In the present study it is clear that the importance given to fidelity as a means of HIV prevention was presented by the vast majority of the adolescents. In our society, the representation exists that to have extramarital affairs is natural for the man, while fidelity is a characteristic attributed to the women(18). However, the adolescents of both sexes gave a great deal of importance to the fidelity of both the man and the woman.
Despite the promotion of condom use being effective, the proposals relating to delaying the initiation of the sexual life, of abstinence and of fidelity to one partner, have also proved successful in preventing HIV/AIDS in the context of predominantly heterosexual transmission. Conversely, programs that only adopt virginity until marriage and fidelity are not effective methods of prevention(10).
This study focused upon the knowledge, values, practices and representations of the adolescents that are indicators of their individual vulnerability to HIV. However, it is important to note that individual vulnerability is strongly influenced by the social vulnerability. By comparing the differences of these indicators in the females and males, it must be comprehended that one of the social and cultural issues that directly influences the sexuality of the adolescent, and consequently their vulnerability to STDs, is the relationships of power that demonstrate the existing gender relations in society. It is necessary to comprehend that the concept of gender is different to that of sex. Sex refers only to biology, while the former is related to social representations related to being a man and being a woman. These concepts are culturally and historically constructed, and influence the attitudes of men and women(17).
In Western society, the representation of man is related to freedom of sexual practice, with them having to prove early on that they are potent and sexually capable, and have the power to decide when and how to perform sexual intercourse, without control over their impulses, being valued for their many sexual experiences. On the contrary, the representation of women is linked to sexual inexperience, to concealment, conformism, passivity, dependence on men, with little or no negotiating power, being valued for their chastity and fidelity to their partner(17). These, historically constructed social representations, rooted in the culture in which adolescents live, must be considered and approached when the aim is to reduce vulnerability to HIV/AIDS.
The global experience after the onset of AIDS has taught that successful prevention must be based on three elements: a) information and education; b) health services and social assistance tailored to the needs of the community that suffers the consequences of the epidemic; and c) social support. These three perspectives, are associated with the individual, social and institutional/state dimensions of vulnerability to AIDS. Therefore, the approach to the variables that focus on health should not be restricted to the biological aspects, with it being necessary to include the cultural and social values that permeate the individual constructions.
In the present study deficits in knowledge regarding HIV transmission and safe sex practices can be perceived. It can also be perceived that although techniques of condom use are known, this does not mean that there is constant use. Some values linked to gender representations were confirmed, such as the valorization of the virginity of the woman, the greater knowledge of the techniques of condom use by the boys, the embarrassment of carrying condoms by the girls, and the embarrassment of refusing to have sexual intercourse in situations of risk on behalf of the boys. However, an evolution regarding autonomy and negotiating power of the girls concerning condom use can also be perceived.
It is worth noting that for the reduction in the vulnerability of adolescents to HIV it is necessary to work with them beyond the techniques of prevention, bringing out the cultural and social elements that contribute to the unequal relationships between the sexes, discussing them, challenging them and remaking them so as to contribute to the construction of a way of life that is directed in favor of health. The disclosure of the vulnerability concept which overcomes the limits of the concept of biological risk, addressed in this study, contributes in this respect to the advancement of knowledge, allowing a wider view for health professionals who work with the adolescent public.
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