Challenging Dogma


...Using social sciences to improve the practice of public health

Friday, April 27, 2007

Marginalization of Women in Poverty by AIDS/HIV Initiatives: A Result of Reliance on the Health Belief Model & Inadequate Assessment- Kate Russell

Public health HIV/AIDS prevention programs for women have only recently come about and many of these programs are failing to curb the rising rate of women infected with HIV, especially women living in poverty (1). Many early prevention programs geared towards women highlighted promiscuity and injection drug use as main causes for infection and placed blame on women for this disease portraying them as vectors rather than victims of the disease (2). This blame placing further lowers women’s self worth, increasing their risk of participating in high-risk behaviors. Most prevention programs geared towards women have relied on the health-belief model; believing that once women are informed of ways to prevent HIV infection (abstinence and condom use) they will be able to put these ideas into practice to decrease their own risk of infection. These programs fail to take into account social and behavioral risk factors, such as poverty, depression, gender inequalities and the vast array of other problems plaguing these women, as well as the inability of some women to negotiate safer sex practices with their partners. This paper aims to address these issues and how public health initiatives have failed these women.
Women in poverty as a ‘risk group’
In the U.S. the proportion of women infected with HIV has more than tripled since 1985 (1). Seventy one percent of new HIV infections in 2005 were women (3). However these statistics do not tell the whole story. HIV/AIDS disproportionately affects women living in poverty. Nancy Stoller, Professor of Community studies at the University of California states, “HIV among women is a disease of the poor, the uneducated, and the ghetto-ized (4).” Among areas with high rates of HIV-infected women, the women most affected are poor, belong to communities that are racially or ethnically oppressed, or are drug users (2). Women with any of these characteristics are less likely to receive care and services, and for women with all three characteristics it is nearly impossible to get any access to care or services.
For many of these women, HIV prevention may not be their highest concern. AIDS is just another of a long list of serious health problems experienced by this population (5). These women have other, more pressing concerns, such as finding money for food, rent, etc. They may be dependent on their partner for these things and therefore are not in a position to press for safer sex practices and condom use. For example, a study of African American women in Los Angeles showed that women who depended on their partners for money for rent were less likely to use condoms than women who were not dependent (6).
Current AIDS/HIV Prevention Programs
Many HIV/AIDS prevention programs that target women living in poverty are failing to curb the rising rates of infection among this group. Many of these programs utilize the health belief model, which ignores social and behavioral risk factors that are the underlying causes that put these women at risk for infection. The following HIV/AIDS prevention initiatives and programs are examples of Public Health’s continued use of this flawed behavior theory.
A recent HIV/AIDS prevention initiative put forth by the CDC is entitled Advancing HIV Prevention: New Strategies for a Changing Epidemic. Despite the progressive sounding name, the strategy is based on the continued use of the Health Belief Model and lacks needs assessment for women living in poverty as well as minorities and other at risk groups. This program includes four aims. The first of which is to include HIV testing in regular medical care. The program allows for the fact that many high risk populations are not getting regular medical care by aiming to include testing outside of the medical environment in bars, bathhouses, homeless shelters and prisons. The initiative focuses also on preventing new infections by working with HIV positive individuals and their partners and increasing partner notification programs. The last strategy is to further decrease HIV transmission from mother to child (7).
The program’s main focus is on individuals with a known HIV positive diagnosis. The belief is that by targeting these individuals to modify their behavior to reduce infection rates. A main focus of this initiative is Partner Counseling and Referral Services (PCRS). While counseling services for partners of HIV positive persons is certainly important, it focuses on stable relationships in which the serostatus of both partners are willing to receive counseling and know their serostatus. However, for high risk groups, many relationships are unstable and HIV serostatus is unknown. This program aims to increase knowledge of HIV serostatus by offering HIV testing as a routine part of medical care and by offering testing services outside of the medical environment. However, a study by the CDC showed that the most common reason for getting tested was not because the test was offered or recommended by a health-care facility or provider (10% for men, and 17% for women) but because of illness (42%) which can occur long after infection (8). A large drawback of this program is its sole focus on individuals with a known positive serostatus, some of whom will need ongoing prevention services to ensure a lasting change in behavior. Others may be unwilling to participate in a program that requires them to contact previous partners and may fear others finding out their serostatus. Also, though the program may be able to increase the number of individuals who know their serostatus, there is no guarantee that individuals found to be positive for HIV will be able to procure the drugs they need to treat their infection.
Other programs, such as New York City’s recent distribution of millions of condoms in the Subway, solely focus on distribution of condoms, without consideration that many of these women at risk are unable to negotiate the use of condoms, even when they are available. Bedimo et al. found that women in their study who did not consistently use condoms stated reasons for non-use as a lack of trust in the reliability of condoms to protect them, a lack of desire for pregnancy prevention, and the male partner’s refusal to use condoms (9). Increased availability of condoms will not address any of the reasons for these women’s inconsistency in condom use. Programs to address these issues should consider increased education for these women, including how to negotiate safe sex practices with their male partners.
Failure of the Health Belief Model
Many other programs focus on educating women about routes of transmission and condom use and utilize the Health Belief Model. The belief is that if women are simply told that they are at risk for this disease and they can prevent it through condom use, they will. However, most women in U.S. at risk for HIV are already aware that they are at risk and that condom use can prevent transmission but these women are unable to insist on safe sex practices due to power imbalances in their relationships (10). Schneider states “Knowledge of HIV transmission and its prevention does little good if women do not have the necessary social status and economic independence to negotiate sexual relations with their partners or to chose not to sell sex (2).”
Nyamathi et al. studied AIDS-related knowledge, perceptions and behaviors of impoverished Latina women. The study found that women at risk correctly identified themselves as ‘at risk’ and correctly identified methods of transmission and prevention methods, i.e. condom use and abstinence. They even tended to overestimate the risk of contracting HIV/AIDS. Surprisingly, the investigators conclude the paper by recommending culturally sensitive education programs to increase knowledge of susceptibility and modes of transmission as a solution for the higher prevalence of AIDS among minority women (11). Though they acknowledge that greater knowledge did not lead to safer behavior, they instead suggest perceived vulnerability as a better method to change behavior. This is turning once again to the health belief model. Rather than focus on social reasons, they focus on perceived vulnerability to HIV as a way to scare women into safer behaviors.
Another study by Gedlen et al. tested the use of the health belief model to promote safe sexual behaviors in women. They found that women were motivated to try to use condoms by their beliefs about susceptibility, severity, and barriers. However these women failed to continue to practice protective barriers in the long term, declaring them ‘burdensome’ (12). Though it may have worked to scare women into practice safer behaviors in the short term, only by addressing the social and behaviors causes of the women’s behaviors can you have a lasting impact.
The Need for Needs Assessment
Current prevention programs are addressing only surface issues of what places these women at risk. Learning the perspective of these women and their own perception of their HIV risk through needs assessment will enable public health professionals to tailor unique programs to address social and behavioral factors that place these women at heighten risk for HIV/AIDS. Programs that will truly help these women will incorporate three necessary concepts: community involvement, empowerment, and self-efficacy. Communities should be involved in the planning and executing of prevention programs. A program entitled SISTA: Sisters Informing Sisters About Topics on AIDS is based on the social cognitive theory is finding success in implementing social-skills based training programs to reduce risk behavior among African American women, who are particularly at risk for infection (15). Though African Americans account for only 13% of the population, they accounted for 66% of AIDS cases in 2005 (3). Programs that are not only culturally sensitive, but also involve the community will have the greatest effect on this population. Involving the community will not only allow for peer educators and support groups, but will include involvement of male partners. This is vital in order to decrease infection rates in women. The Advancing HIV Prevention initiative does include partners, but this only affects stable relationships. Involvement of all males to educate them about their role in HIV prevention for women is necessary.
Educational programs for women need to emphasize empowerment, self-efficacy, and communication skills. These will provide women with the skills necessary to negotiate safer sex practices with their partners. Many studies looking at HIV/AIDS in women have found that a lack of self-efficacy and power imbalances result in a lack of condom use but many prevention programs still focus solely on instructing women to use condoms to prevent infection, without providing them with skills necessary to negotiate the use of condoms with their partners. A study by Hetherington et al. demonstrated that one of the reasons African American women in their study continued to practice high risk behavior despite their knowledge of AIDS was their perceived powerlessness in negotiating condom use (11). Women who perceive their partners as dominant in their relationships have less confidence in their ability to negotiate condom use and a greater fear of negative consequences with their partners for demanding safer sex practices (13). A needs assessment for these women will allow for programs tailored to these populations that will be able to address underlying issues placing them at risk to provide for long-lasting, successful HIV prevention.
Conclusion
The lack of appropriate HIV/AIDS prevention programs for women living in poverty is due to the use of the Health Belief Model and a lack of needs assessment for these women. Programs continue to focus solely on education about risk factors and condom use despite growing evidence for a need for programs that address underlying social reasons affecting these at-risk women such as poverty, depression, and power-imbalances in relationships.
There is an urgent need for programs that address these issues in order to curb the rising rates of HIV infection among women living in poverty. Initiatives should take a multi-focal approach and involve communities as well as educate and empower women to be able to protect themselves from infection.
References:
1. amfAR, Women and HIV/AIDS, www.amfar.org
2. Schneider, B and N. Stoller. Women Resisting AIDS: Feminist Strategies of Empowerment. Philidelphia, PA: Temple University Press, 1994.
3. Center for Disease Control and Prevention. AIDS/HIV. www.cdc.gov
4. Stoller N. Lessons for the Damned: Queers, Whores, and Junkies Respond to AIDS. New York, NY: Routledge, 1998.
5. Ward, M. A different disease: HIV/AIDS and health care for women in poverty.
6. Farmer, P. Women, Poverty and AIDS: Sex, Drugs, and Sexual Violence. Monroe, ME: Common Courage Press, 1996.
7. Center for Disease Control and Prevention. Advancing HIV Prevention: New Strategies for a Changing Epidemic. Atlanta, Georgia: AVERT. http://www.cdc.gov/hiv/topics/prev_prog/AHP
8. CDC. Advancing HIV Prevention: New Strategies for a Changing Epidemic. Morbidity and Mortality Weekly Report. 2003; 52(15):329-332
9. Bedimo, A., Bennett, M., Kissinger, P., and R. Clark. Understanding barriers to condom usage among HIV-infected African American women. Journal of the Association of Nurses in AIDS Care. 1998; 9(3): 48-58.
10. Farmer, P. Infections and Inequalities: The Modern Plagues. University of California Press, 2001.
11. Nyamathi, A., Bennett, C., Leake, B., Lewis, C., and J. Flaskerud. AIDS-related Knowledge, Perceptions, and Behaviors among Impoverished Minority Women. Journal of American Public Health 1993; 83: 65-71.
12. Gielen, A., Faden, R., O’Campo, P., Kass, N., and J. Andrson. Women’s protective sexual barriers: a test of the Health Belief Model. AIDS Education and Prevention 1994; 6(1): 1-11.
13. Pittsburg AIDS Task Force. AIDS/HIV Prevention Programs. http://www.patf.org/preventionPrograms.asp
14. Hetherington, S., Harris, R., Bausell, R., Kavanagh, K., and D. Scott. AIDS prevention in high-risk African-American women: behavioral, psychological, and gender issues. Journal of Sex and Marital Therapy.
15. Soet, J., Dudley, W., and C. Dilorio. The Effects of Ethnicity and Perceived Power on Women’s Sexual Behavior. Psychology of Women Quarterly 1999; 23(4): 707-723.

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