RESEARCH ARTICLES

Conjugality and a multi-professional health team's social representations of HIV/AIDS

Mariana de Sousa Dantas^I; Rebeca Coelho de Moura Angelim^II; Fátima Maria da Silva Abrão^III; Denize Cristina de Oliveira^IV

^I Nurse. Master in Nursing by the Associated Program of Post-Graduation in Nursing at the University of Pernambuco and Sate University of Paraíba. Recife, Pernambuco, Brazil. E-mail: nanasdantas_@hotmail.com
^II Nurse. Master in Nursing by the Associated Program of Post-Graduation in Nursing at the University of Pernambuco and Sate University of Paraíba. Recife, Pernambuco, Brazil. E-mail: rebecaangelim@hotmail.com
^III Nurse. Ph.D. in Nursing. Coordinator and Professor at the Association Program of Post-Graduation in Nursing at the University of Pernambuco and the State University of Paraíba. Recife, Pernambuco, Brazil. E-mail: abraofatima@gmail.com
^IV Nurse. Ph.D. in Public Health. Professor at the State University of Rio de Janeiro. Brazil. E-mail: dcouerj@gmail.com

DOI: http://dx.doi.org/10.12957/reuerj.2015.15672

ABSTRACT

Taking a descriptive, qualitative, structural approach to social representations theory, this study examined the content and structures of a multidisciplinary health team's social representations of HIV/AIDS, as expressed by the team in general and by those members with a partner. Analysis of free evocations in response to a questionnaire applied to 86 health professionals in Recife, Brazil, between 2011 and 2013, resulted in a corresponding four-quadrant chart in which prejudice displayed a negative affective and attitudinal quality; while treatment, associated with treatment adherence and prevention, denote clinical knowledge about the phenomenon. Among those with a partner, disease appeared in the 4th quadrant and prevention in the 3rd, maintaining the clinical view of the syndrome. The representations characterize the clinical/medicine approach and stigma, expressed as social prejudice.

Keywords: Social representations; acquired immunodeficiency syndrome; health personnel; sexual behavior.

INTRODUCTION

Infection with Human Immunodeficiency Virus (HIV) has manifested in a global way, over the 30 years of its discovery. Therefore, a heterogeneous epidemic is configured, whose progression occurs, geographically and socially, in local and specific population groups such as injecting drug users, men who have sex with men and sex professionals in the various continents of the planet¹.

Regarding the evolution of the epidemic of Acquired Immunodeficiency Syndrome (AIDS) in the global context, data from the Joint Program of the United Nations about HIV/AIDS (UNAIDS) indicated that in 2012, there were 35.3 million people living with HIV, and 2.3 million people with new infections and 1.6 million of deaths from complications related to the disease².

According to the official report of this Program, it is believed that access to antiretroviral therapy has contributed to the decline of new infections since 2001. However, the phenomenon presents significant challenges given the high mortality and discrimination faced by people living with HIV/AIDS (PLWHA)². Thus, it emphasizes the importance of participation of civil society in response to the AIDS epidemic in all countries.

In Brazil, the data showed 39,185 cases of the disease in 2012. Among the capitals of the Northeast region, the city of Recife ranks 2nd position related to higher incidence rates corresponding to 39 cases per 100,000 inhabitants³.

It should be noted that the progress of the phenomenon was crucial for HIV/AIDS to be considered a social object, since the evolution of the unfamiliar into something familiar, leading to the emergence of various representations⁴.

Therefore, it is appropriate to conduct a study of the social representations of HIV/AIDS by health team professionals, considering the scarcity of scientific research involving this group. Also, it worth noting the complexity of the approach about the conjugal bond, whose personal conducts and interrelations may suffer social, economic and cultural influences.

Concerning conjugality, it would emphasize the importance of developing studies about this topic, focusing on the interactional dynamics, capable of promoting theories and more contextualized clinical practice⁵.

The conjugal relations to be understood as individuals conjugation between the couple incite the need for a better understanding of the various approaches, including psychological guiding's covered by such studies⁶.

Faced with the exposed, it is worth mentioning a study performed by nurses, whose social representations about the vulnerability permeate interpersonal relationships, denoting non-use of condoms and the invisibility of HIV in sexual-affective relationships ⁷.

Thus, these proposals suggest the following question: Which are the representational contents of HIV/AIDS attributed by health team professionals in the context of conjugality? This study aims to analyze the contents and structures of social representations of HIV/AIDS by the multidisciplinary health team, presented by professionals in general and those with a partner (a).

METHODOLOGICAL THEORETICAL REFERENTIAL

This study is part of the Multicenter Project title: The transformations of health care and nursing in times of AIDS: social representations and nurses and professionals memories in Brazil⁸.

The reflections about HIV/AIDS manifests by highlighting that the health-disease process assumes in the social research field, making timely use of the Social Representation Theory (SRT) in the various fields of research due to the theoretical alternatives production that contemplate the different, the unusual, unexpected, from an interchangeable context of answers and ways of thinking 9.

On this perspective, human and social sciences have influenced the construction of knowledge about the health-disease process. Thus, the use of SRT allows the formulation of social representation of a given object and enables the understanding, organization and adequacy of professional practice and healthcare ¹⁰. In this perspective, the construction of the representations is influenced by the relationship between social groups, established between the HIV positive person, health professionals and the general society¹¹.

This is a descriptive study with a qualitative approach based on structural aspects, elaborated by Jean-Claude Abric, Theory of Social Representations. Performed from 2011 to 2013, at health services networks for HIV/AIDS in the city of Recife, Pernambuco, Brazil. The sample consisted of 86 selected employees, intentionally, incorporated into the multidisciplinary team whose care practices directed at people affected by HIV/AIDS occurred in more than six months, in Specialized Care Services (SCS) and Testing and Counseling Center (TCC).

A questionnaire of socio-demographic variables was applied, as well as the free evocations. Data analyzed with the help of Evocations Free Technical ensured the elaboration of a framework of four houses through the 2005 version of the software EVOC -Ensemble de Programmes Permettantl Analyse des Evocations, to identify the structure of representational contents¹².

It is known that this technique, also called prototypical analysis, enables that the mental projections of the participants to be apprehended quickly, objectively and spontaneous, by citing three to five words or expressions that can imagine about one or more inductors terms (stimuli) detected by hearing or visualization, to assimilate the notion of reality^12-14. In this context, for the present study, it was used the term inducer HIV/AIDS requesting five words or expressions that come to mind of health professionals when thinking about that inductor term.

It is noteworthy that the study followed the ethical and legal requirements contained in Resolution No. 466/2012, of the National Health Council ¹⁵. The research project was approved by the Research Ethics Committee of the University of Pernambuco (UPE) under Certificate of Presentation for Ethics Assessment (CPEA) of 01080.0.097.000-11 number, being kept as confidential and personal integrity of health professionals who signed the Informed Consent.

RESULTS AND DISCUSSION

In this study, the socio-demographic data of the members of the multidisciplinary health team were expressed by the variables: the role played in the team, gender, age, sector of activity and time of work intended for PLWHA, as explicit in Table 1.

TABELA 1: Distribuição dos participantes quanto à função, ao sexo, à idade, ao setor e tempo de atuação. Recife, Brasil, 2013.

Thereby, it is clear that the studied multidisciplinary team consisted of 74 (86%) SCS workers and 69 (80.2%) women; 34 (39.5%) members aged 46-55 years and 64 (74.4%) of operating time to PLWHA in the period up to 15 years of service. Regarding the professional category, highlight 24 (27.9%) physicians, followed by 14 (16.3%) nursing technicians and 14 (16.3%) psychologists, as the largest portion of the studied group.

About the application of EVOC, the results are shown in tables of four houses expressing the representational structure of the HIV/AIDS for all 86 members of the multidisciplinary team and 54 workers living with a partner (a) in the following topics.

Meanings of HIV/AIDS to the multidisciplinary health team

The meanings of HIV/AIDS for the multidisciplinary health team were presented in Figure 1, through the evocations analysis results of the group of 86 participants of the health care team that provides assistance to PLWHA. The test application gathers 439 words associated with the term HIV/AIDS, with 145 different words. Thus, the minimum frequency was determined (6), the average frequency of evoked words (12) as well as the Middle Rang (3.0) which corresponds to the average position of the words used for analysis.

FIGURA 1: Análise do termo indutor "HIV/AIDS" das evocações de profissionais da equipe multiprofissional de saúde. Recife, PE, Brasil, 2013.

The dimensional identification of evocations in quadrants, exposes the termsprejudice, hope, overcoming, sadness, fear, fighting, abandonment, suffering as attitudinal and emotional elements; treatment, adhesion to treatment, prevention, help, care and chronic-disease, featuring a conceptual approach and knowledge of the object; and the evocations disease and death determining an imagery dimension about HIV/AIDS, as shown in Figure 1.

Regarding the organization and structure of social representations, presents peripheral elements exposed in the superior and inferior right quadrants, which are resistant to transformations, that surround and protect the central nucleus, and confer meanings about a particular representation¹⁶. On the other hand, the contrast zone, despite covering low-frequency words, they were remembered first and may arouse the interest of researchers ¹³.

Meanings of HIV/AIDS for professionals who live with a partner

The results of evocations analysis refer to the group composed of 54 workers of the multidisciplinary team, who live with a partner, as shown in Figure 2, which shows the representational components arranged in each quadrant.

FIGURA 2: Análise do termo indutor "HIV/AIDS" evocado pelos profissionais de saúde que vivem com companheiro (a). Recife, PE, Brasil, 2013.

In this context, the professionals of this group raised a total of 269 words related to the inducing stimulus HIV/AIDS and 102 different words. It was used minimum frequency (6), medium frequency of evoked words (12) and the Middle Rang (3.0).

Dimensional analysis of evocations keeps attitudinal elements and affective prejudice, fear; the conceptual approach and knowledge about HIV/AIDS expressed by treatment, adhesion to treatment, prevention, care; and evocations death, the disease in imagery dimension about the phenomenon. See Figure 2.

The results show a slight displacement of some representational elements of HIV/AIDS by professionals with a partner, between the quarters in comparison to the four houses charts composed of the evocations of the entire multidisciplinary team. Thus, the expression disease was displaced from the 1st quadrant to the contrast area, constituting a subgroup of the possible central nucleus treatment and the prevention element showed a peripheral mobility from the 2nd to the 3rd quadrant. Nevertheless remained the clinical character and stigmatization that the members of this group have incorporated about the disease.

Among the peripheral elements is observed a reduction of the terms of the group with a partner. Furthermore, adhesion to treatment words remained on the 1st periphery and death in the 2nd periphery, assumed by the incurable aspect of the disease.

The organization of social representation presents a particular modality, specific, which both elements of the representation are ranked as well as any representation is organized around the central nucleus, consisting of several elements that give meaning to the representation¹⁶. Thus, the possible central nucleus of the representation of HIV/AIDS was displayed in the left superior quadrant by the most frequent elements and most immediate evocation prejudice and treatment.

The central nucleus indicates that the most frequent and important elements can group less significant expressions, synonyms, and prototypes associated with the object. These elements appear even through social perception, consisting of social thought, which allow to sort and understand the reality experienced by individuals¹⁶.

It is noteworthy that between the central terms, prejudice was the most frequently invoked by the participants in a negative attitudinal dimension associated with imagery content presented by contrast lexicon disease. It refers to the social prejudice that several groups established about HIV/AIDS since its appearance. This term expresses supposedly discriminatory attitudes of society towards PLWHA. Thus, it identifies the permanence of a negative attitude towards the disease and can cause a process of stigmatization of PLWHA.

In this perspective, the representations of the disease are based on the meanings and previous knowledge of social groups, being the AIDS long associated with deviant behavior^17,18 generating the omission of serology to avoid suffering prejudice. The social and historical phenomenon of AIDS has generated many doubts, feelings and prejudices that influenced the social imaginary and had provided negative conceptions about the disease stigmatizing it and compromising the quality of life of PLWHA¹⁹.

In this sense, it is noteworthy that stigma is defined as a label, definition of stereotyping, separation, loss of status and discrimination in a context in which power is exercised. This condition is quite common in today's society and affects a number of diverse population groups because the dominant social paradigms induce to the increase of health inequalities, becoming a problem for the population as hinder or inhibit access to various structural features, interpersonal and psychological that could be used to avoid or minimize health problems and hinder the effectiveness of public health interventions²⁰.

It is worth noting that the current health demands require paradigm changes both in services and in the academic education of health professionals ²¹. Thus, these findings require (re) think the education and practice of the professionals involved, going beyond a dichotomy between information and education, isolation of knowledge, crystallization of practices, and to be able to understand the complexity of individuals and their everyday relations²².

Regarding the central expression treatment, the same interact positively with the peripheral elements adhesion to treatment and prevention, translating technical and scientific knowledge of professionals about HIV/AIDS. The expressions related to treatment refer, overcoat, to drug and clinical therapy, suggesting the advent of antiretroviral therapy (ART) as a determinant for the prolongation of life of PLWHA, as well as increased life expectancy and improved quality of life.

In this context, we highlight the chronicity of AIDS, as it constitutes a present reality in the countries that facilitate access to ART²³. From this allusion, AIDS has evolved into a chronic disease in the modern era, making the patients most tolerant to therapy. Furthermore, the treatment is directed to the comorbidities not related to HIV, reducing risks and preventive care²⁴.

Regarding the use of antiretroviral drugs and living with the disease, notes about the chronicity of HIV/AIDS are configured as new challenges for health teams, which should encourage continued treatment and acceptance of seropositive status by a society that still perceive the disease as a problem of others²⁵.

Thereby, about relational aspects between the quarters, the peripheral element prevention and contrast care exhibit positive connotation and a dimensional perspective of knowledge, whose association is given by the possibility of living with the disease and adopting behaviors able to avoid contamination with viruses. So is related to both, professional security dealing with the HIV-positive individual, as to their personal and social relationships, in addition to holding a safe sexual practice by professionals and individuals in general.

The study shows prevention in a practical and real focus, whose preventive practices go beyond the use of condoms. It points out that the prevention measures are essential to control the epidemic, leaving managers and health professionals to provide information to the public about these practices²⁶.

Corroborating this premise, the need for prevention by health workers, besides converging to health education, may be associated with concerns related to viral transmission or reinfection, able to induce therapeutic gap¹⁷.

As for the negative meanings about the object, it was possible to identify in the 3rd and 4th quadrant, the terms death and fear, respectively, and death characterized by image dimension, socially elaborated from the initial identification of the disease. In this context, it is worth mentioning that fear seems to suggest the qualm of the investigated group to the exposure to the virus and the possibility of infection. Still, other research points out that the fear of the disease is associated with prejudice, raising conflicts in interpersonal relationships¹¹.

The results of this study also reinforce those found in another research, showing the displacement of the term death and the appearance of the chronic lexicon disease in AIDS representation of contrast zone, pointing a representational change observed in recent years²⁷.

By contrast, fear is closely linked to social fear of being contaminated with the virus, because of all the particularities evidenced in the health-disease process, in addition to the fear of death experienced by the PLWHA.

People and groups from the communication and cooperation process create the representations, and when to acquire own life, manifest themselves and form new representations. This sharing process reinforced by tradition constitutes the social reality and thus, it is possible to change attitudes by the representations produced or inherited of the society²⁸.

It is believed that the represented object implies some definitions from a consensus view of reality, shared by the same group and, although divergent of meanings built by another group, can serve to a process of everyday exchanges, which constitute the dynamic of social representations²⁹.

From this perspective, the epidemiological evolution of HIV/AIDS and access to information denote different concepts, meanings, feelings and ideas that are giving a new configuration to the social representation of AIDS²⁶. It should be noted that the existence of representations is given by the need to exchange information between people, making it possible to understand the every day presented problems, which confrontation requires behavior adjustments and physical and cultural domain²⁸.

Concerning HIV/AIDS and conjugality situation, the conjugal identity involves the sharing of values, attitudes and care, and is associated with external factors linked to individuals³⁰. The fixed relationship makes the involved in believing it supports any form of prevention since stability in the relationship would be capable of conferring protection against virus infection. These ideas permeate the vulnerability context for the partner, due to the trust deposited on fidelity in a sexual partnership, which is not always observed in reality¹¹.

Thus, about the social representation of HIV/AIDS by health professionals living with a partner, were shown as part of four houses positive characteristics related to the terms treatment, adhesion to treatment, prevention, care; and negative characteristics determined by the elements prejudice, death, fear. However, this representation was not different from that observed in the general group (with and without a partner), which suggests the lack of variability in the construction of social thought due to this condition.

CONCLUSION

The social representations of HIV/AIDS by members of the multidisciplinary health team of this study, signaled important aspects of the phenomenon, being possible to identify their meanings expressed by all professionals and those living with a partner.

In this research, the data showed that social representations of HIV/AIDS by professionals with a partner were consistent with the representations of the general group, with regard to the relevance of the dimensional aspect of knowledge about the object, noting the clinical and biomedical approach about the phenomenon highlighted by the clinical and medicamental approach, accompanied by the stigmatization of the disease and its affected.

It is noted that the imagery, attitudinal and knowledge content about a particular object can influence the processes of formation of social thought. Justifications and arguments that feed this idea are capable of producing socially constructed meanings and senses to HIV/AIDS.

The data also proposed representational content focused on the technical and scientific conception of the study object, associated with healthcare practice. It emphasizes the need to develop studies with health professionals, because this group, especially members of the nursing team, is a vulnerable population to health problems and disorders, with a view to exhausting working hours, working conditions and stress capable of causing inadequate care practices, and that may interfere in unsatisfactory way in conjugal relations of these people. It is also appropriate to emphasize the need to expand studies to deepen the questions about conjugality in the various social components, from different theoretical propositions.

Furthermore, the study has some limitations and fragilities related to the quantity of participants, suggesting the expansion of research about social representations guided by the structural approach involving a more significant number of health professionals, at all health care levels.

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