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Enfermedades de transmisin sexual y respuetas alternativas para la educacin: perspectivas de la comunidad de Monteverde, Costa Rica
Sexually transmitted diseases and avenues for education: community perspectives from Monteverde, Costa Rica
A study assessing and evaluating the attitudes, perceptions and beliefs of sexually transmitted diseases; how these diseases are transmitted and prevented; community awareness of high risk groups; and the more effective way of disseminating educational material about them.
Un estudio de avaluacin y evaluacin de las actitudes, percepciones y creencias de las enfermedades de transmisin sexual, cmo se transmiten y evitan estas enfermedades ; la conciencia de la comunidad de los grupos de alto riesgo, y la manera ms eficaz de difusin de material educativo acerca de ellos.
Sexually transmitted diseases--Prevention--Costa Rica--Puntarenas--Monteverde Zone
Public health--Costa Rica--Puntarenas--Monteverde Zone
Community Health 2003
Health care services
Sexually transmitted diseases--Education--Costa Rica--Puntarenas--Monteverde Zone
Sex education--Costa Rica--Puntarenas-- Monteverde Zone
t Community Health
SEXUALLY TRANSMITTED DISEASES AND AVENUES FOR EDUCATION: COMMUNITY PERSPECTIVES FROM MONTEVERDE, COSTA RICA Cristina Caldern Andrea Freidus Kelly Gillin James Schwar Claudia Weiner Field Methods for Community Health Monteverde Institute June 21 to August 3, 2003
Team Background The research team was comprised of five members with diverse public health practice and research backgrounds. Cristina Caldern B.A., speaks advanced Spanish and is a health clinic Andrea Freidus B.A., speaks advanced Spanish and has provided rural patient health services in the Dominican Republic. Kelly Gillin B.A., sp eaks basic Spanish and volunteers with an AIDS organization. James Schwar M.P.A., speaks intermediate Spanish and has conducted research abroad into national HIV/AIDS media campaigns. Claudia Weiner B.S.N., speaks basic Spanish, is a visiting nurse ser vice case manager, and has administered school based public health awareness programs. The team also wishes to thank the many people who were valuable contributors to the project (see Appendix F). Introduction In 2002, Monteverde area community member s identified Sexually Transmitted Diseases timeliness also parallels re cent national legislation, which ensures the rights of HIV positive literature and key informant interviews, however, underscore the scarcity of local STD and HIV/AIDS s 6). For example, syphilis, gonorrhea, and human papilloma virus have been cited as the most l numbers are unknown (8). The literature and key informants also emphasized the need to address the family values, and the religious implications of sexual activi ty (9, 10). more, who live in the region. Knowledge, beliefs, and attitudes concerning their transmission, and prevention strategies were examined. The study also identified the most wide audience through educational programs. Purpose of the Study The purpose of this study was five fold. It assessed and evaluated the following: 1) attitudes, knowledge and beliefs about routes of transmission, s ymptoms, and prevention; 3) community awareness of at risk groups and categories of people and groups; 4) current sources of information and local perceptions of their efficacy; and 5) the most effective avenues to disseminate primary information and educa tion to a range of community audiences. The overarching purpose of the study, however, was to present the findings to support health professionals, educators, and community leaders in the enhancement of existing or development ucation programs.
Methods This exploratory pilot study used the Community Participation approach, which was designed to (11, 12). Data were collected through a qu antitative socio demographic instrument (see Appendix C) and qualitative focus group interviews with female and male Costa Ricans, who were Monteverde area residents aged 18 years or more. Four focus groups were conducted: two for women and two for men. Community leader referrals and one on one outreach were used to recruit participants. Contextual data were collected through semi structured and unstructured interviews with key informants, community leaders, and local health officials. Male team mem groups. There were at least 4 interviewees within each focus group. At no time were participants questioned about individual behavior; only their perceptions of categories of people and groups were sought (see Appendix D). A written record of each focus group was made. With participant permission, some sessions were audio taped, excerpts of which were used to enhance content analysis. Researchers and faculty advisors had ex clusive access to the data. Audiotapes will be destroyed after 3 years. The study received IRB approval and signed consent forms were received from each interviewee prior to their participation (see Appendix E). All collected data were reviewed after each focus group session, translated into English, and analyzed for content. A matrix was developed, listing corresponding female and male responses to each question posed. Contrasting and complimentary themes were then identified. Results There were a total of 21 focus group participants: 13 women and 8 men (see Appendix A). The mean and median age of all participants was 30 years. The mean age for female participants was 36.1 years and 25 years for the males. The median age for female p articipants was 38 years old and 21 years for the men. There were a greater number of divorced and single participants (both genders) than married individuals and those with partners. More than half of all respondents had at least one child and 9 of th e 21 individuals had lived in the Monteverde area for 2 decades or more. The majority had either primary or secondary level educations. Six people, however, reported university level educations. Seventeen of the total number of focus group members state d they had some organized religious affiliation. More than half were Roman Catholic. Data analysis identified 5 main themes: 1) the participants were generally knowledgeable of ) abstinence; 4) the use and effectiveness of condoms; and 5) availability and suggestions for information (see Appendix B
misconceptions 1 Hongos, syphilis, gonorrhea, chacras (herpes), HIV, and AIDS were listed as perceptions: 1) there was no cure for HIV/AIDS; 2) it was transmitted through sexual activity and blood; 3) anyone could be affect ed; and 4) it affects the immune system. In contrast to the female participants, male respondents noted that HIV/AIDS treatment was very expensive. The women viewed HIV and AIDS as indistinguishable, and misperceived condoms as ineffective and HIV transm ission through cavities and saliva. Female participants cited male infidelity with local Ticas and female tourists (extranjeras), female prostitution, and machismo as contributors to the spread of HIV/AIDS 2 Both genders, however, acknowledged that HIV/ AIDS was a problem or potential community problem, because of infidelity or the sexual behavior young people. Some men also suggested that only drug users have HIV/AIDS. Similarly, transmission from pregnant women to their fetuses also was a shared conce rn. Women said they would not react negatively to a friend who confided in them that they had HIV, while fright, lack of knowledge, or fear of contagion would contribute to negative reactions to a person with HIV, according to the men. from Tables 2a and 2b in Appendix B are noted according to the theme number with its corresponding group responses. All participants cited abstinence 3 as the most effective but unattainable prevention strategy, even though some women perceived condoms as a completely ineffective prophylactic against HIV 3 The males, however, repeatedly mentioned condoms as very effective 4 Both genders mentioned the avoidance of blood exchanges through needle use as a preventive strategy, although men specifically menti oned the need for care in hospital use of syringes. A key finding was that some confirmed by several key community informants. Condoms, according to both genders, were used chiefly in family planning 4 and were cited as readily available in community pharmacies, the clinic, bars, gas stations, and pulperas. Female participants, however, said that only women access condoms from the clinic. Male respondents identi fied bars and gas stations as the main sources for condoms. Both female and male participants concurred that charlas at the clinic 5 in the schools, and from HIV/AIDS information. The women also cited parents as an important educational source, but added that some parents and children experience difficulty in discussing the subject. There was cross gender agreement that young people, and men, in particular, required HIV/AIDS educational programs. Both genders also expressed the need for school based education classes. The male respondents, however, suggested the classes in the clinic be made interesting and fun 5 The men als o mentioned the church as a possible educational setting. Oppositely, the women indicated the church was an unlikely venue. The male participants pointed to rumors that were spread among young people as another reason that more youth oriented educational programs are needed.
Conclusions For example, the women referred to news reports they believed had stated that HIV was too small a virus for condoms to be effective. 4 Still, the clinic and media appear to be the most valuable educational avenues for information, if the programs are designed for multiple audiences, are sci entifically accurate, and are clearly articulated. Men and young people should be targeted as the primary audiences for educational programs. For example, the women commented that the lack of education and information about HIV 5 place young people, in pa rticular, and men at great risk. Therefore, accessibility of information and education programs also is requisite. Clearly, school based classes, clinic and home based charlas, theme oriented television/radio shows, such as the Original Canopy Tour broa dcast, in addition to books and pamphlets appear to be the most effective avenues for the dissemination of Limitations Temporal constraints limited recruitment, data collection, and data analysis; additional time might have resulted in additional focus group sessions from a broader cross section of the community and addressed data variability. Moreover, additional key informant exchanges would have enhanced team awareness of nuances in colloquial language and input into the final report. Language was another limitation; valuable data may have been lost during sessions that were taped, but were inaudible due to poor equipment, and not understood by the less fluent Spanish speaking team members. Recommendations for Future Studies In conjunction with local health officials, school based educators, and community input, future research could assist in the enhancement or development of charlas in the clinic, programs that target young people in the schools, and outreach efforts for adult community members via one on one, familial, or informal discussions. Researchers could further support the community educational programs and information dissemination services through follow up program evaluations. Ways to dispense free condoms also could be addressed: cost constraints, potential social barriers, the impact of clinic condom distribution polic y, and barriers that discourage male participation in current preventive efforts. Future research also could address the potential HIV/AIDS studies could focus o n young people (18 years or younger) in the Monteverde area.
References 1. Nat Scrimshaw. (2003). Executive Director, Instituto Monteverde. 2. University of South Florida Globalization Research Center, Instituto Monteverde, CETAM. (2002) Development and Tourism Survey Santa Elena, Costa Rica: University of South Florida Globalization Research Center, Instituto Monteverde, CETAM. 3. Patricia Jimenz. (2003). Co 4. Asociacin Rotaria 3H. (1998). Ley general sobre el VIH SIDA. San Jos, Costa Rica: Asociacin Rotaria 3H. 5. Organizacin Panamericana de la Salud. (1998). Hacer frente al SIDA: Prioridades de la accin pblica ante una epidemia mundial (Publicacin Cientfica No. 570). Washington, DC: Organizacin Panameric ana de la Salud 6. Schifler, J., & Madnga, J. (1996). Las gavetas sexuales del Costarricense y el riesgo de infeccin con el VIH: Editorial. San Jos, Costa Rica: Imedrex. 7. Tobas Bolaos. (2003). ATAP, Clnica de Monteverde. 8. Dr. Maur cio Quesada. (2003). Director, Clnica de Monteverde. 9. Guillermo Murillo. (2003). Director, Asociacin Agua Buena. 10. Susan Scrimshaw. (2003). Dean, School of Public Health, University of Chicago Illinois. 11. Cornwall, A., Jewkes, R. (1995). What is participatory research? Social Sc ience and Medicine, 41 1667 1676 12. World Health Organization. (1995). A rapid assessment of health seeking behavior in relation to sexually transmitted diseases, p. 1. Geneva: World Health Organization.
Appendix A Table 1. Socio Demographic Characteristics According to Frequency by Focus Group Characteristic Focus Groups Total Women Men Age 18 20 2 3 5 21 22 1 2 3 23 25 26 27 2 2 28 30 30 or more 8 3 11 Gender 13 8 21 Civil State Married 2 2 4 Single 4 3 7 Divorced 5 3 8 Separated Other 2 2 Number of Children 0 4 1 5 1 2 4 1 5 3 4 2 3 5 4 5 1 1 5 or more 2 2 Years Residing in Region 1 5 1 1 2 6 10 1 1 2 11 15 1 1 2 16 20 2 2 20 or more 6 3 9 Educational Level None 1 1 Primary 9 3 12 Secondary 2 2 University 3 3 6 Other Religion
None 3 1 4 Catholic 5 7 12 Evangelic 2 2 Other 3 3 Appendix B Table 2a. Matrix of Themes and Comments by Female and Male Focus Group Participants Women Theme Men eso son hombres que son machistas porque tal vez no han visto y creen que eso es una 1. Awareness and Misconceptions adultos ya estn casados y practican sexo solo con una persona, en la mayora (The people who believe this (that HIV is invented) are men who are machistas because they have not seen they will be fa ithful, but some do believe.) (Because the majority of adults is married and practice sex with only one person, in the majority of cases.) pusiera dos o tres (condones) cuando que mata las (I tell him to protect himself (husband), to put two or three condoms on when he is going to have sex somewhere else.) defenses.) calle cualquier cosa se puede traer a (If a husband is out on the street with someone else, then they can bring something back to their wife.) mujer pero un hombre no, el hombre 2. Fidelity and Machismo (A woman is able to faithful, but a man no, a man is never faithful.) (You have to be suspicious 100% of the time for your entire life.) estar con mujeres porque son hombres, pero si a una mujer anda (Machismo is when men are with women because they are men, but if a woman goes out with a man she is
criticized.) (There is a lot of machismo. (Only God is faithful.) pero no las que viven en (They (men) use them more with female tourists, but not with those who live in Monteverde.) hacer lo que quiera, la mujer no vale (I am a man and I can do what I want, a woman is worth nothing.) Table 2b. Matrix of Themes and Comments by Female and Male Focus Group Participants Women Theme Men 3. Abstinence (abstinence). refresco al frente, y no lo tomas, te ests absteniendo de beberlos o sea (For example, you have a soda in you are abstaining from drinking it, 4. Condoms pass through.)
(I use a condom very often.) (Yes, young people use them more to prevent pregnancy.) (People most often use it to prevent pregnancy.) (Here there is no information about this (HIV). 5. Availability and Suggestions for Information charlas tienen que ser informales y divertidas, para que la gente no se (In the clinic, but the talks need to be informal and fun, so that the people are not bored.) conoce poco sobre quin pueda ayudar y que realmente est (There are very few people who know very much about who can help and who really are prepared to give these talks.)
Appendix C Informacin General Edad ____ Sexo: ___ Hombre ___ Mujer Estado civil: ___ Casado(a) ___ Soltero(a) ___ Divorciado(a) ___ Separado(a) Nmero de hijos(as) _______ Edades de hijos(as) _________________________ Cuntas personas viven en su casa? _________________ Cuntos aos vive en la regin de Monteverde? ________________ Nivel de educacin: ____ Primaria ____ Secundaria ____ Universidad ______ Otra (lista) Ocupacin (trabajo) ___________________ *Religin (opcional) __________________________
Appendix D ¡Buenas tardes! Somos estudiantes del Instituto Monteverde. Estamos haciendo un proyecto acerca de las percepciones en la comunidad de Monteverde sobre las Enfermedades Transmitidas Sexualmente (ETS) y sobre el SIDA/VIH. Estamos interesados en todas sus opiniones y esperamos que todas participaran. Por favor tengan en cuenta que no hay respuestas incorrectas. Esta es una conversacin entre amigas(os). Lo que estamos haciendo es investigar cmo la comunidad aqu obtiene informacin sobre cuestiones de salud y cule s son las mejores maneras de brindar esta informacin. Nos gustara grabar la discusin para que nos sea ms fcil analizar los datos, pero solo lo haremos si todas estn de acuerdo. Hay alguien que no quiere que grabemos? No vamos a pedirles sus nombres y no vamos a hablar de sus comportamientos personales. Solamente los miembros de nuestro grupo van a escuchar la grabacin y despus de 3 aos la cinta va a ser destruida. Los resultados del estudio se van a presentar en una manera en que nadie va a pode r saber cmo respondieron los individuos. Vamos a hablar con otras mujeres (otros hombres) y algunos hombres (algunas mujeres) y nos gustara presentar nuestros resultados a ustedes la semana que viene. Vamos a empezar con una lista de las enfermedades tr ansmitidas sexualmente que ustedes SIDA, Gonorrea, Sfilis, Hongos 1. Que saben ustedes del SIDA? 2. A quin afecta el SIDA? 3. Cmo se transmite? 4. Cmo se puede saber si alguien tiene SIDA/VIH? 5. Cmo se puede evitar el SIDA/VIH? a. CONDONES i. Dnde se consiguen? ii. Qu tanto los usa la gente? Por qu? b. ABSTINENCIA i. Algunas personas creen que la abstinencia es la manera ms efectiva para proteger a la gente contra el SIDA. Que creen ustedes? 6. Qu tipo de tratamiento hay para el SIDA? 7. Qu tan serio creen ustedes que sea el problema del SIDA en Monteverde? 8. Cmo creen ustedes que reaccionara la gente en Monteverde si conocieran a alguien con VIH/SIDA? 9. Cmo obtiene informacin sobre el VIH/SIDA la gente que vive aqu? a. De estas fuentes de informacin, cual es la ms efectiva? b. Cul es la ms usada? 10. Qu grupos creen ustedes que necesitan informacin sobre el SIDA? 11. Cul creen ustedes que sea la manera ms efectiva de educar a las jvenes sobre el SIDA? 12. Quin debe ensearles? 13. Cmo? Dnde? A qu edad? 14. Cul creen ustedes que sea la manera ms efectiva de darle informacin a las mujeres (los hombres) sobre el SIDA? 15. Y a los hombres (a las mujeres)? Appendix E
Forma de consentimiento A Usted se le e st invitando a participar en un estudio que ayudar a identificar los medios ms efectivos para brindar informacin bsica a diferentes segmentos de la comunidad en Monteverde sobre las enfermedades transmitidas sexualmente (ETS). Nosotros haremos esto m ediante la exploracin de percepciones locales sobre las enfermedades transmitidas sexualmente, incluyendo a VIH en Monteverde. Este incluye conocimientos, actitudes, y creencias acerca de las ETS, definiciones, transmisin y estrategias de prevencin. Usted, como parte de este estudio participar en un grupo de discusin de seis a ocho personas del mismo sexo de edades entre los dieciocho y treinta aos de edad por un mnimo de una hora y un mximo de dos horas. La informacin obtenida en estos grupos de discusin ayudar a futuros investigadores en el diseo de materiales educativos para la comunidad. Toda la informacin que usted nos d ser mantenida de manera confidencial y su nombre no ser usado en ninguna de nuestras presentaciones orales o esc ritas. Los resultados de este estudio se presentarn los das 22 y 23 de julio 2003 en el Instituto de Monteverde. Solo los investigadores y la facultad del Instituto de Monteverde tendrn acceso a la informacin. No habr riesgo fsico ni psicolgico a l participar en el estudio. No le preguntaremos sobre su comportamiento individual. La participacin en este estudio es completamente voluntaria y usted es libre de retirarse en cualquier momento sin ninguna penalidad. Como un incentivo por tomar parte en este estudio de investigacin, el Instituto Monteverde les brindar al grupo un refrigerio y transporte. Si usted tiene alguna pregunta sobre esta investigacin, contacte a Dr. Nancy Romero Daza o a Sophia Klempner en el Instituto de Monteverde a tel fono 645 5053 Ext. 111. Se le va a entregar una copia de este formulario de consentimiento. Si a usted le gustara participar en este proceso, por favor firme este formulario. Gracias. _____ Estoy de acuerdo en participar en la investigacin. _____ Yo doy permiso para citar la informacin. _____ Yo doy permiso para que este grupo de discusin sea grabado, trascrito y traducido si es necesario. Otros Comentarios: Nombre: ________________________________________________ Firma: _________________ _____________ Fecha: ____________________________
Appendix F Acknowledgements The research team is indebted to our faculty advisor, Dr. Nancy Romero Daza, and the staff of Instituto Monteverde for their tireless efforts and support: Nat, Elsa, Sophia, Sadie, Odilio, and Tony. We also want to thank the many key informants and commun ity members, who directly contributed to the successful completion of this project: Patricia, Tobas, No, and Anbal. Most importantly, we extend our gratitude to the people of the Monteverde area, who took us into their homes, their families, and their hearts.