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Learn More. Many women continue to become infected with HIV, particularly in the Southeastern USA, despite widespread knowledge about methods to prevent its sexual transmission. This grounded theory investigation examined the decision-making process women use to guide their use or non-use of self-protective measures when engaging in sexual activity. Theoretical sampling was used to recruit a sample of 20 primarily African American women aged between 26 and 56 years, living in rural and urban areas.
Although numerous efforts and ificant resources have aimed to enhance the prevention and treatment of HIV in the USA over the past 20 years, the epidemic continues to have impact, withindividuals acquiring the virus between and Centers for Disease Control and Prevention a.
Specifically, Mississippi ranks ninth in the country in rates of newly acquired infections, and Jackson, the state capital, ranks eighth among US cities in overall prevalence of HIV and fourth in the rate of new infections Centers for Disease Control and P revention b. In the Jackson metropolitan area, African American women are These alarming figures reflect the urgent need for further research to understand and halt the perpetuation of this epidemic. Research related to HIV acquisition among women, particularly minority women living in Southern states, has primarily focused on gaining an understanding of the individual and sociocultural factors that influence the practice of risky sexual behaviours Mallory ; Mullinax et al.
Bontempi, Eng, and Crouse ; Dauria et al. Several studies have investigated the motivations for sexual activity among African American women, particularly when engaging in concurrent sexual relationships Deardorff et al. Social determinants of health, such as marital status, education, food insecurity, illicit drug use, intimate partner violence and sexual abuse contributed to concurrency.
The current study sought to explore how women living in Mississippi came to decide to protect or not protect themselves when engaging in sexual behaviours. While this study was not limited to African American women, the sample of women reflected the HIV epidemic in the state, and the vast majority of those who participated were African American.
The study adopted a grounded theory approach Glaser and Strauss This utilises an inductive process to analyse data without attempting to fit it into any one existing theory Corbin and Strauss Women in this cohort study participated in a study visit at their WIHS site every six months. Eligible participants from the Jackson WIHS cohort were selected for this study from among those who were either 1 infected with HIV within the past 10 years in order to facilitate recall or were 2 HIV-uninfected. A theoretical sample was enrolled to achieve the inclusion of women in important sub-groups in terms of age, race, rural versus urban residence and diagnosis date.
This process occurred in waves to address gaps in the sample identified in data analysis sessions, evolving as analysis occurred to suggest additional factors that might be of importance.
Women who fitted the eligibility criteria with the desired characteristics were approached throughout the study period during their routine WIHS research visits and asked if they would be interested in learning about a sub-study in which they could participate. Participants had to be willing and able to be interviewed about their own sexual behaviours and use of protection and be able to speak at some depth about those experiences. Twenty women agreed to participate from September to Januaryand individual interviews were conducted with 14 HIV-positive and 6 HIV-negative women. Interviews were mostly conducted at the WIHS site, or at their homes.
The mean length of time since HIV-diagnosis was 4. Both HIV-positive and HIV-negative women were enrolled to confirm that the emerging theory would describe decision-making regardless of the outcome of the decision-making regarding acquisition of HIV. Six female graduate psychology students from the Jackson, Mississippi, area were trained in qualitative interviewing and grounded theory by an expert in these methods JTfollowed by a series of role plays and practice interviews to refine their skills, with feedback from experienced researchers on the team DKP and KF.
Following each interview, interviewers composed a series of field notes that described observations of the participant and their impressions of the salient themes that arose during the in-depth interview. The field notes, along with documentation of data analysis and concept development, formed the project audit trail Steubert and Carpenter Other measures for quality control included frequent team meetings among the data collection team to discuss the interviews, as well as review of transcripts and feedback from the senior research team members.
Audio recordings were transcribed verbatim, checked for accuracy against the recordings and de-identified by the interviewers. The first transcribed interviews, along with the corresponding field notes recorded on a standard form, were immediately sent to each member of the research team. The first step in the process was a line-by-line analysis of all of the transcribed interviews, identifying or coding key concepts and segments.
Broad codes were initially ased to blocks of text concerning specific issues related to self-protection from HIV transmission Sbaraini et al. These initial codes were then collapsed into core and supporting sub. The simultaneous process of data collection, coding and analysis, utilising a system of constant comparison, ensured that the interviewers were gathering rich data to describe the process women applied in their decisions to either use or to not use self-protective measures when engaging in sexual behaviours.
This process also allowed the researchers to determine data saturation when it became apparent that no new information was being shared. The research team, which consisted of the interviewers, the principal investigator and two qualitative researchers, met monthly to identify substantive codes, identify processes within the data, as or categorise data using the constant comparative methodology, describe the essential that emerged from the data, and make sampling decisions to clarify and further elucidate the emerging theory Steubert and Carpenter Major emerged and, through the iterative process of diagramming, re-reading the text and returning to the literature, sub that supported the major were identified.
To ensure inter-rater reliability, the first two authors reviewed all of the data for consistency, reviewed discrepancies and identified selections of the text that exemplified themes that emerged from the data. Analysis of the data revealed the existence of an overarching framework, Sexual Silence, which described how the pervasive silence and lack of communication about sex and sex education impacts on women and men at both a societal and individual level.
Within that framework, two and six sub- emerged: 1 Importance of Relationships with Male Partners described how the centrality of a relationship with a male partner took precedence in decision-making, and 2 Perceptions of Risk described assumptions and mis-conceptions about HIV transmission and HIV prevention, which put women at risk when engaging in high-risk sexual relationships.
The theoretical model we developed, describing the process used by women to determine their use of self-protection Figure 1illustrates how the Importance of Relationships far outweighs the Perception of Risk, surrounded by an environment of Sexual Silence. As the twoImportance of Relationships and Perception of Risk emerged, it became apparent that they were embedded in the overarching background of Sexual Silence at the intimate partner level, as well as at the societal level.
At the partner level, Sexual Silence discouraged frank discussion about risk within couples; at a societal level, it also discouraged education about sex within families and communities, as well as in schools. The category Sexual Silence is best illustrated in a story told by Lakisha pseudonymrecounted after reflecting on her own transmission, which was probably in her lates, when involved in drugs and not thinking about HIV when having unprotected sex:. It was hid in the homes with families that were diagnosed, you know?
Conversely, an HIV-negative participant shared that she did talk with her partners about STDs and using condoms prior to having sex, although it was uncomfortable:. Interviews with the 14 HIV-positive women revealed that all but one, who traded sex for money to support her drug dependency, were infected by a partner who they believed was in a committed monogamous relationship with them.
Woven throughout the shared stories of these 14 women was the centrality of their need to be in a relationship with a man. Women expressed a strong need to have a relationship with a man to fill a perceived void in their lives. They described this void as being caused by loneliness, poor self-esteem or from the need for comfort, companionship and love. Women described seeking the presence of a man to bolster self-esteem, and in some cases by the social desirability of being in relationship with a man.
The need to fill a void appeared to have crowded out the sense these women might have had regarding the need to protect themselves from STIs:. And, you know, I guess … all I was just thinking about just having that, that little comfort … from that person …. A contrary case illuminated how drug use could supersede the need for a relationship with a man. In this case, another way to fill the void was her drug use, which was funded by prostitution:.
I very seldom used condoms. At that time, it was all about me and my drug of choice. Her perception of risk was great, but the weight she placed on the importance of her relationship with drugs was much greater. Women had a strong desire to preserve their relationships by not pressing men too much to use condoms or by asking them to get tested for HIV. Although the risk of getting HIV was not an ever-present fear in these women, they were strongly aware of the risk of getting other STIs. Women described not asking partners to use condoms because they feared he would think she was carrying an STI.
This was especially true in a long-standing relationship:. We were together about six years …. In these situations, either her perception of risk was lowered since she felt that he could be trusted not to bring STIs home to her, or she was concerned about his reaction if she insisted:.
Several women in this study described how due to an unspoken commitment, they trusted their partners to not bring home STIs. In almost every case, HIV-positive women in this sample reported they had been infected by their main partner, who either knew that he had HIV and did not tell her, or who became HIV-positive during their relationship as the result of unprotected sex in concurrent relationships.
Because of this, there was a strong sense of betrayal associated with their HIV diagnosis:. I mean I loved him. You say you this. Because I wanted to believe that, you know, he was the only one, you know, I was the only one that he was being with despite, you know, what people would tell me …. Yeah, I wanted to just really believe that. Over time, women described becoming more comfortable in the relationship and beginning to trust, which informed decisions to forgo the use of condoms. In some cases, the decision to forgo condom use was a of trust.
And I think I let my guard down to, um, maybe prove a point to him that I did trust him, and [laughs] wow. I always ask people do they have HIV, and they say no then, you know … you get kind — you get comfortable.
I guess once you grow, have feelings for someone … and you trust them …. For these women, if pregnancy was not a concern due to their age or if they were in a long-term relationship, they did not perceive their sexual relationship as risky and therefore it never crossed their mind to use a condom:. If you do anything make sure you use protection … from being pregnant.
Stories woven onto the background of silence surrounding sex appear to be generational. Not only did women talk about the lack of knowledge they received growing up, many women described their own difficulties talking about sex with their children. Most stories from these women about sexual knowledge centred on pregnancy prevention, and when their parents discussed getting an STI, the consequences were trivialised. There were other s where women described not thinking about condom use because they were in a long-term relationship.
In these stories, the women described being comfortable in their relationship and never considered that they were at risk:. I was always protected [when I had affairs]. It look like [the men I had affairs with] were more better than [he was]. In each of the stories of the HIV-positive participants, they describe that at some point they were tested for a STI, either because something just did not feel well or as part of a routine examination.
Because these women did not perceive themselves at risk for STIs, condom use never crossed their minds, and when they received the diagnosis of HIV, they described their shock and devastation:. This form of denial seemed to be a persistent factor in the decision-making process for women in this study:. Unlike the stories told by women where condom use never crossed their mind, another participant told this story:. It did [cross my mind to use protection], but I was just careless at the time ….
And it just was something … spare [ sic ] of the moment. Spare [ sic ] of the moment things that turned into a lifetime of trouble …. Yes [I was aware of HIV at that time].
The following story from a participant who was HIV-negative and a nurse, further illustrates how this form of denial puts women at-risk for infection. While she and her husband, who is HIV-positive, are now vigilant in condom use, her story describes her past history of risky behaviours:. I almost never [used condoms], to be completely honest, almost never …. This is something that happens to other people. On the other hand were stories, primarily from HIV-negative women, who were very aware that it could happen to them, either from a past history of an unexpected STI or a family member or friend who was diagnosed with HIV.
These women tended to be vigilant about condom use due to their memory of that situation:. A recurring theme embedded in the narratives of the women in this study, was about assumptions about HIV. Although several women admitted to engaging in sex with multiple partners, most of the women described their relationships as long term, though not always mutually monogamous.
Though they did not view themselves as promiscuous, many of them admitted to having suspicions that their partner was promiscuous, yet this assumption, based on a stereotype of female promiscuity, may have led to poor decisions regarding self-protection. Other stereotypes these women described related to men who they felt were more likely to be HIV-infected.
Men who were tall and thin, or who had lost weight, were suspected of being HIV-positive, along with men who had been incarcerated and men on the down low heterosexual men who also have sex with men. While several women described walking away from a relationship with men who fell into these stereotypes, for those whose partner was on the down low, these women often had no idea until their HIV test was positive.
For others, engaging in unprotected sex with men who did not fit these stereotypes proved to be unsafe:. Although some of the women insisted on partner testing and initially insisted on condom use, their desire for a relationship built on trust diminished their agency to negotiate for consistent self-protection. This phenomenon was best described by a participant who entered into relationship and, although she had been tested, she could not get her partner to test. About one month after she broke of the relationship, he called informing her that she needed to be tested:.
And I put all my paperwork in there and showed it to him. Like other stories, Markisha regretted not being more insistent on testing and acknowledges that she could have insisted on condom use. Although she accepts blame for her diagnosis, she also feels a sense of dismay, stating:. I do get mad with myself because I feel like, you know, I let myself down ….
Why me, Lord?Women want sex Crouse
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