Evaluation of self-esteem in people living with HIV/AIDS in the city of Ribeirão Preto, state of São Paulo, Brazil

Abstracts

Esse estudo de corte transversal teve como objetivo avaliar a autoestima de pessoas com HIV/aids e relacioná-la com fatores sociodemográficos e clínicos. Participaram 331 pessoas com HIV/aids, que faziam acompanhamento em dois serviços de referência de um município do interior paulista, entre 2007 e 2010. Os dados foram coletados por meio de entrevistas individuais, utilizando-se Escala de autoestima de Rosenberg. Dos entrevistados, 167 (50,5%) eram do sexo masculino, faixa etária predominante entre 30 e 39 anos (42,0%). Com referência às variáveis relacionadas à sexualidade, 82,2% declararam-se heterossexuais e 84,6% referiram ter se infectado por via sexual. Quanto à avaliação da autoestima, a média obtida foi de 25,25. Os impactos negativos quer físico, social ou emocional da infecção pelo HIV, revelaram a necessidade dos serviços de saúde estarem preparados para oferecer assistência integral às pessoas com HIV/aids, valorizando os fatores psicossociais.

Síndrome da Imunodeficiência Adquirida; Autoestima; Autoimagem

ORIGINAL ARTICLE

Carolina de Castro Castrighini^I; Renata Karina Reis^II; Lis Aparecida de Souza Neves^III; Sandra Brunini^IV; Silvia Rita Marin da Silva Canini^V; Elucir Gir^VI

^IMaster's Student in the Graduate Program in Fundamental Nursing of the University of São Paulo (USP) at the College of Nursing of Ribeirão Preto (EERP, as per its acronym in Portuguese). São Paulo, Brazil. E-mail: [e-mail]

^IIPh.D. in Nursing. Doctoral Professor of the General and Specialized Nursing Department of EERP/USP. São Paulo, Brazil. E-mail: [e-mail]

^IIIPh.D. in Nursing. Coordinator of the Tuberculosis Program of the City Health Department of Ribeirão Preto. São Paulo, Brazil. Email: [e-mail]

^IVPh.D. in Nursing. Professor of the Federal University of Goiás at the College of Nursing. Goiás, Brazil. E-mail: [e-mail]

^VPh. D. in Nursing. Associate Professor of the General and Specialized Nursing Department of EERP/USP. São Paulo, Brazil. E-mail: [e-mail]

^VIPh.D. in Nursing. Full Professor at EERP/USP. São Paulo, Brazil. Email: [e-mail]

Correspondence

ABSTRACT

This cross-sectional study aimed evaluate self-esteem individuals with HIV/AIDS and relate it to sociodemographic and clinical factors. 331 people with HIV/AIDS, who were assisted at two referral centers in a city of the interior of São Paulo state between 2007 and 2010, participated of the study. Data were collected through individual interviews, using self-esteem scale of Rosenberg. 167 (50.5%) of the respondents were male, mostly between 30 and 39 years old (42.0%). Considering the variables related to sexuality, 82.2% reported being heterosexual and 84.6% referred to have been infected by sexual intercourse. Regarding the evaluation of self-esteem, the avarage score was 25.25. The negative impacts whether physical, social or emotional of HIV infection revealed the need for health services prepared to offer comprehensive care for people with HIV/AIDS, valuing the psychosocial factors.

Descriptors: Acquired Immunodeficiency Syndrome. Self-esteem. Self image.

RESUMEN

Este estudio transversal objetivó evaluar autoestima individuos con VIH/SIDA y relacionarla con factores sociodemográficos y clínicos. 331 personas con VIH/SIDA, asistidas en dos centros de referencia en una ciudad del estado de São Paulo entre 2007 y 2010, participaron del estudio. Datos fueron recolectados a través de entrevistas individuales, utilizándose la escala de autoestima de Rosenberg. De los encuestados, 167 (50,5%) eran hombres, en su mayoría entre 30 y 39 años (42,0%). Con referencia a variables relacionadas con sexualidad, 82,2% reportaron ser heterosexual y 84,6% informaron de que habían sido infectados por relaciones sexuales. En cuanto a la evaluación de autoestima, la pontuación media fue de 25,25. Impactos negativos sea físicos, sociales o emocionales de la infección por el VIH revelaron la necesidad de servicios de salud preparados para ofrecer una atención integral para personas con VIH/SIDA, valorizando factores psicosociales.

Descriptores: Acquired Immunodeficiency Syndrome. Self-esteem. Self-image.

INTRODUCTION

After the introduction of the Highly Active Anti-Retroviral Therapy (HAART), infection by the Acquired Immunodeficiency Virus (HIV)/AIDS became a chronic condition. Currently, people living with HIV/AIDS have the opportunity to live with the disease rather than for the disease as in the 1980's, which enables, among other aspects, transforming the syndrome, culturally perceived as an outcome of an announced death, into a disease with a chronicity perspective, allowing for changes in values, beliefs, habits and individual and collective knowledge.¹

This situation implicates a challenge in the delivery of comprehensive health care to these individuals, as the possibility of deconstructing the idea of imminent death emerges when the diagnosis of the HIV/AIDS infection is received. The change must also occur among health professionals, in order to remove their focus from death, aimed at dealing with the disease and comprising social and emotional aspects of those living with HIV/AIDS in the care provided.²

Despite the great benefits resulting from the use of HAART, mostly prolonging survival and the chronicity of the infection, treatment deeply marks the individuals, affecting their physical, social and mental well-being and involving negative feelings such as depression, distress and fear of dying, which interfere in their self-esteem and identity.³

Although the progress of the medication therapy has contributed to reduce mortality rates, it is known that in the HIV positive context, important psychosocial consequences are observed, such as depression, low self-esteem and prejudice.⁴

Self-esteem refers to the degree of consideration or respect an individual has for oneself and a way to measure the values attributed to his/her own judgments and capabilities. It is related to the concept of oneself and influenced by the way he/she is seen by loved ones.⁵

Due to the chronicity of the HIV infection, important changes may occur in the life of these carriers, emerging new needs to be understood and dealt with, enhancing the already existing ones. Understanding the self-esteem of people living with HIV/AIDS is essential. Increased self-esteem makes the individual living with HIV perceive him/herself in a positive way; on the other hand, those with affected self-esteem may see themselves as more limited and discouraged,⁴ with great implications to mental health. Given the circumstances, the present study had the aim to evaluate the self-esteem in people with HIV/AIDS and to relate it to sociodemographic and clinical factors.

METHODS

This is a cross-sectional study performed in two outpatient clinics specialized in the care of individuals with HIV/AIDS in a city in the interior of the state of São Paulo, Brazil. Individuals who participated in this study were carriers of HIV/AIDS, clients of the public health system, registered in the studied service, who received care in the period between 2007 and 2010 and met the inclusion criteria: being aware of the HIV/AIDS diagnosis, older than 18 years, assisted at the outpatient clinics in the study location, coming to medical appointments booked during the study period, with physical and emotional conditions to participate in the interview.

Data were collected by means of individual interviews and the Rosenberg Scale was used to evaluate self-esteem, in a version translated and adapted to Portuguese. This instrument consists of Likert scale (1=strongly agree, 2=agree, 3=disagree, 4=strongly disagree) with 10 questions, of which five evaluate positive feelings regarding him/herself (In general, I am satisfied with myself; I feel I have a few good qualities; I can do things as well as most people, as long as they are taught to me; I feel I am a valuable person, at least to the same rate as other people; I have a positive attitude about myself). The other five items evaluate negative feelings (Sometimes I feel useless; I feel no satisfaction for the things I have accomplished; I feel I have not much to be proud of; Sometimes, I feel really useless, incapable of doing things; I wish I had more respect for myself; Most of the time I tend to feel I am a looser).

The interval may vary from 10 (ten items multiplied by 1) to 40 (ten items multiplied by 4). As per this instrument, higher scores indicate higher self-esteem.⁷

Sociodemographic and clinical data were collected using a specific questionnaire for this study.

A database was constructed, organized into Excel spreadsheets and processed and analyzed in the Statistical Package for Social Sciences (SPSS) software, version 15.0. Descriptive statistics was employed in data analysis.

Participants were informed regarding the objectives of the study, data confidentiality and the assurance of anonymity. Data collection was initiated after the signature of the Free and Informed Consent Form. The research proposal was approved by the Research Ethics Committee of the University of São Paulo at Ribeirão Preto College of Nursing, protocol No.0699/2006, according to the recommendations on resolution 196/96 of the National Health Council.

RESULTS

From the 650 registered individuals, 331 (50.9%) individuals who sought for treatment in the period between 2007 and 2010 were interviewed. From these, 167 (50.5%) were male, with a predominant age range between 30 and 39 years (42.0%), 134 (40.5%) were single and 212 (64.0%) had been educated up to primary school (Table 1).

Regarding reproductive and sexual features, 272 (82.2%) claimed to be heterosexual, 43 (13.0%) homosexual and 16 (4.8%) bisexual, 280 (84.6%) claimed to have been infected by sexual contact, 13 (3.9%) by blood and 38 (11.5%) claimed not knowing how they were infected.

Regarding clinical variables, 133 (40.2%) presented TCD4 higher than 500 cells/mm³, 135 (40.8%) between 499 and 201 cells/mm³, and 63 (19.0%) lower than 200 cells/mm³.

Regarding the self-esteem evaluation performed in the study population, the mean was 25.25 with a minimum of 17 and maximum of 37.

Table 2 presents the mean and the standard deviation found in the employment of the Self-esteem Scale of Rosenberg in the participants of this study.

Table 3 presents the mean, minimum and maximum values of self-esteem and the standard deviation found in the population studied according to the variables considered. Individuals who affirmed being separated/divorced, who could not report their exposure category and had no comorbidity presented higher self-esteem means, with statistically significant differences.

DISCUSSION

The individuals interviewed in this study were young, with primary education and most claimed being infected by sexual contact, revealing the need for population awareness regarding prevention methods against HIV. These findings were also seen in a study that suggested people living with aids have lower education and are young.⁸

Among the 331 individuals with HIV/AIDS participating in this study, 164 (49.5%) were women. HIV/AIDS infection in women has progressively increased, representing approximately 50% of the cases worldwide and 30% of the cases in Latin America.⁹ In Brazil, between 1980 and 2011, 608,230 cases of aids were identified, 397,662 in men and 210,538 in women. This ratio between genders, in Brazil, has decreased throughout the years, demonstrating a female feature in the epidemics.¹⁰

In this study, the predominant sexual orientation was heterosexual, in 82.2% of the HIV/AIDS cases. In a study performed in the city of São Paulo, the heterosexual relation was found to contribute to the epidemics among women.¹¹

Results related to education are consistent with the social profile of the epidemics in Brazil, which reaches people with lower education,¹² with 161 (48.6%) individuals presenting only incomplete primary education in this study. In addition, 13 (3.9%) individuals claimed to be illiterate and only 16 (4.8%) had a college degree.

Regarding the poverty in the epidemics, education is used as an indirect variable of the socio-economic situation, influencing the increase of the epidemics among people with lower education.¹³ Universal education is one of the goals of this millennium to the United Nations. For the UN, education is a way to cope with the aids epidemics, as there is a relation between low education and increased risk for infection.¹⁴

Comparing the results of this study to a sample of people living with HIV/AIDS in the state of Minas Gerais, some variables were observed to be similar, for instance: low education, the most affected age range, transmission by sexual contact and the marital status of the individuals studied. Nevertheless, there were different data, such as most of the sample being female.

Among the interviewees, 176 (53.2%) presented comorbidities related to the HIV infection or to HAART, information also found in another study.¹² The advent of this therapy brought benefits such as the reduction of opportunistic infections and an increase in life expectancy due to the chronicity of the disease,¹² however, its use must be considered a risk factor for cardiovascular and metabolic disorders, requiring guidance to a healthy lifestyle.¹⁶

Among the individuals in this study, 133 (40.2%) demonstrated good clinical parameters and markers of the infection by HIV, observed by the high CD4 cell count. Ever since the beginning of the HIV epidemics, monitoring CD4 lymphocytes has been used as a predictive laboratorial parameter of the HIV infection prognosis and also as an indicator of risk for opportunistic infections.¹²

In this study, the mean score for self-esteem was 25.25. In other Brazilian studies,^17,18 the mean for self-esteem was higher, suggesting that people living with HIV/AIDS present worse self-esteem when compared to individuals living with other chronic diseases. Self-esteem levels influence self-confidence and valuing, and may lead the individual not to care for his/her health, for personal care, not to believe in him/herself and not to search for treatment.¹²

The low self-esteem found in people living with HIV/aids in this study may be related to the negative consequences of dealing with the HIV/AIDS infection, broadly reported in literature as depression, and social and emotional isolation.^12,19

Self-esteem is an essential aspect in the creation and maintenance of health, hope and quality of life. People living with HIV/AIDS may have their self-esteem damaged due to the social impact the infection may cause in their lives, associated to the stigma of the disease, as potentially fatal. Nevertheless, the infection also causes physical and social limitations in the life of the individuals, such as the loss of a life project, the need for restructuring habits, dealing with new limitations at work and family relations.¹²

Regarding the items in the Rosenberg Self-Esteem Scale, the highest mean (2.98) observed was related to question 9, in which individuals agreed with the statement "Most of the time I tend to feel I am a looser" and the one presenting the lowest mean was question 10 (2.19), in which participants agreed with "I have a positive attitude (thoughts, actions and positive feelings) about myself", diverging from another study¹⁵ that found the highest mean in question 4 and the lowest in item 8.

Increased self-esteem favors individuals with HIV/AIDS in having positive feelings about themselves; on the other hand low self-esteem makes them feel more limited and discouraged.⁴

Self-esteem may be predisposed by social features such as gender, age, marital status as well as by the disease affecting oneself.²⁰ In the present study, there was a statistically significant difference between the means in self-esteem and in marital status (p<0.001). Single individuals present the worst mean compared to married, separated/divorced and widowed individuals. These findings may suggest single individuals have less family support and, therefore, less support for coping with life with HIV/AIDS and worse self-esteem.

A study performed in Brazil demonstrated family support is important in coping with the disease,¹⁵ and in the quality of life.²¹ A study performed with children living with HIV/AIDS in Ruanda, Africa, showed that both self-esteem and family support are important for their resilience in coping with the disease. ²²

The variable category of exposure also identified statistically significant differences (p<0.001) among the means, as individuals who were exposed by blood had worse self-esteem. Such findings were also seen in another study¹⁵ and they can be related to the fact that most individuals included in this category were infected by sharing syringes and needles when using injectable drugs and that this is a vulnerable population under the individual, social and pragmatic point of view.

In addition, individuals who had no comorbidities had better self-esteem means (p=0.022). The presence of comorbidities or co-infections may implicate in larger physical²³ and psychological²⁴ symptoms, among people living with HIV/aids with reduced self-esteem.

Hence, strategies must be adopted in health services to offer comprehensive care to the health of this population, such as physical activities, individual therapy and group activities. Physical exercises have been an influencing factor in self-esteem as demonstrated in an investigation performed with a group of aged individuals.²⁵ In another study, the physical activity helped achieve a better perception in the satisfaction of the participants in life.²⁶

Moreover, the implementation of group activities among health professionals and people living with HIV/AIDS generates familiarity and the perception of needs, feelings and afflictions,²⁷ in addition to building a setting for emotional support, exchange of experiences and understanding the psychosocial aspects of living with HIV/AIDS,²⁸ and constituting an important strategy for the education and promotion of health.

CONCLUSION

The present study identified that people living with HIV/AIDS have lower self-esteem when compared to individuals living with other chronic diseases. A significant relation was found between self-esteem and the variables marital status, category of exposure and presence of comorbidities.

Few studies which evaluated self-esteem in people living with HIV/AIDS were found in the national and international literature, although it is an important theme for this population. Hence, more investigations regarding the variables that may influence the self-esteem of these individuals are necessary, in addition to the relation of self-esteem to health, quality of life and therapy compliance.

Negative impacts whether physical, social or emotional of the infection by HIV/AIDS require attention and engagement from health services to work on interventions that favor self-esteem, for instance physical exercise, individual therapy and group activities, since they may influence the way to deal with the disease. The self-esteem evaluation may help reveal individuals who may demonstrate difficulties in committing to treatment and to self-care. Nurses, as the fundamental professionals in the health team, must be prepared to deliver comprehensive care to individuals with HIV/AIDS, given their emotional and clinical features.

REFERENCES

References

• 1. Schaurich D, Coelho DF, Motta MCG. A cronicidade do processo saúde-doença: repassando a epidemia da Aids após o anti-retrovirais. Rev. Enferm da UERJ. 2006; 14 (3): 455-462.
• 2. Polejack L, Costa LF. Aids e conjugalidade: o desafio de com(viver). Impulso, Revista de Ciências Sociais e Humanas. 2002; 13 (1): 131-9.
• 3. Carvalho CML, Braga VAB, Galvão MTG. AIDS e saúde mental: revisão bibliográfica. DST J Bras Doenças Sex Transm. 2004; 16(4): 50-5.
• 4. Castanha AR, Coutinho MPL, Saldanha AAW, Ribeiro CG. Aspectos psicossociais da vivência da soropositividade ao HIV nos dias atuais. PSICO. 2006 Jan-Abr; 37(1): 47-56.
• 5. Townsend MC. Enfermagem psiquiátrica: conceitos de cuidados. 3^a ed. Rio de Janeiro (RJ): Guanabara Koogan; 2002.
• 6. Rosenberg M. Society and the adolescent self-image. Princeton(US): Princeton University Press; 1965.
• 7. Dini GM. Adaptação cultural, validade e reprodutibilidade da versão brasileira da escala de auto-estima de Rosenberg [Dissertação]. São Paulo (SP): Universidade Federal de São Paulo. 2001.
• 8. Carvalho CML, Galvão MTG, Silva RM. Alteração na vida de mulheres com síndrome da imunodeficiência adquirida em face da doença. Acta Paul Enferm. 2010; 23(1):94-100.
• ⁹ Unaids (SW). Joint United Nations Programme on HIV/AIDS, World Health Organization. AIDS epidemic update. Geneve (SW): Unaids; 2007.
• 10. Ministério da Saúde (BR). Secretaria de Vigilância à Saúde. Programa Nacional de Controle e Prevenção de DST/AIDS. Semanas epidemiológicas: 26^a-52^a de 2010/1^a-26^a de 2011. Bol Epidemiológico: AIDS DST. 2010 jul-dez 2011 jan-jun;1: 3-26. Brasília; 2011. Ano 8, n.1.
• 11. Gabriel R, Barbosa DA, Vianna LAC. Perfil epidemiológico dos clientes com HIV/AIDS da unidade ambulatorial de hospital escola de grande porte: município de São Paulo. Rev Latino-am Enferm. 2005 Jul-Ago; 13(4):509-13.
• 12. Reis RK, Santos CB, Dantas RAS, Gir E. Qualidade de vida, aspectos sociodemográficos e de sexualidade de pessoas vivendo com HIV/aids. Texto Contexto Enferm. 2011 Jul-Set; 20(3):365-75.
• ¹³ Ministério da Saúde (BR). Secretaria Executiva. Coordenação Nacional de DST e Aids. Políticas e diretrizes de prevenção das DST/aids entre mulheres. Brasília (DF): MS; 2003.
• 14. Neves LAS, Canini SRM, Reis RK, Santos CB, Gir E. Aids e tuberculose: a coinfecção vista pela perspectiva da qualidade de vida dos indivíduos.Rev Esc Enferm USP.2012: 46(3): 704-10.
• 15. Brito TRP, Vilela MP, Goyatá SLT, Arantes CIS. Avaliação da auto-estima de portadores de HIV/aids do município de Alfenas, Minas Gerais, Brasil. Rev Gaúcha Enferm. 2009 Jun; 30(2):190-7.
• 16. Guimarães MMM, Greco DB, Junior Oliveira AR, Penido MG, Machado LJC. Distribuição da gordura corporal e perfis lipídico e glicêmico de pacientes infectados pelo HIV. Arq. Bras. Endocrinol. Metab. 2007; 51: 42-51.
• 17. Vargas TVP, Dantas RAS, Góis CFL. A auto-estima de indivíduos que foram submetidos à cirurgia de revascularização do miocárdio. Rev Esc Enferm USP. 2005; 39 (1):20-1.
• 18. Silvério CD, Dantas RAS, Carvalho ARS. Avaliação do apoio social e da autoestima por indivíduos coronariopatas, segundo o sexo. Rev Esc Enferm USP. 2009; 43(2):407-14.
• 19. Cechim PL, Selli L. Mulheres com HIV/AIDS: fragmentos de sua face oculta. Rev Bras Enferm. 2007 Mar-Abr; 60(2): 145-9.
• 20. Magalhães CHT, Pereira MD, Manso PG, Veiga DF, Novo NF, Ferreira LM. Auto-estima inativa de oftalmopatia de Graves. Arq Bras Oftalmol. 2008; 71(2):215-20.
• 21. Seidl EMF, Zannon CMLC, Tróccoli BT. Pessoas vivendo com HIV/aids: enfrentamento suporte social e qualidade de vida. Psicologia: Reflexão e crítica. 2005; 18(2):188-95.
• 22. Betancourt TS, Meyers-Ohki S, Stulac SN, Barrera AE, Mushashi C, Beardslee WR. Nothing can defeat combined hands (Abashize hamwe ntakibananira): protective processes and resilience in Rwandan children and families affected by HIV/AIDS. Social Science and Medicine. 2011 Set;73: 693-701.
• 23. Silveira MPT, Guttier MC, Pinheiro CAT, Pereira TVS, Cruzeiro ALS, Moreira LB. Depressive symptoms in HIV-infected patients treated with highly active antiretroviral therapy. Rev Bras Psiquiatr. 2012; 34:162-7.
• 24. Cheade MFM, Ivo ML, Siqueira PHGS, Sá RG, Honer MR. Caracterização da tuberculose em portadores de HIV/AIDS em um serviço de referência de Mato Grosso do Sul. Rev Soc Bras Med Trop. 2009 Mar-Abr; 42(2):119-25.
• 25. Chaim J, Izzo H, Sera CTN. Cuidar em saúde: satisfação com a imagem corporal e autoestima de idosos. Mundo Saúde. 2009; 33(2):175-81.
• 26. Gomes RD, Borges JP, Lima DB, Farinatti PTV. Efeito do exercício físico na percepção de satisfação de vida e função imunológica em pacientes infectados pelo HIV: ensaio clínico não randomizado. Rev Bras Fisioter. 2010 Set-Out; 14(5):390-5.
• 27. Galvão MTG, Gouveia AS, Carvalho CML, Costa E, Freitas JG, Lima ICV. Temáticas produzidas por portadores de HIV/aids em grupo de autoajuda. Rev Enferm UERJ. 2011; 19(2):299-304.
• 28. Souza N R, Vietta EP. Benefícios da interação grupal entre portadores do HIV/Aids. DST J bras Doenças Sex Transm. 2004; 16(2):10-7.

Evaluation of self-esteem in people living with HIV/AIDS in the city of Ribeirão Preto, state of São Paulo, Brazil

Evaluación de la autoestima en personas que viven con el VIH/SIDA en el municipio de Ribeirão Preto, estado de São Paulo, Brasil

Publication Dates

• Publication in this collection
  06 Feb 2014
• Date of issue
  Dec 2013

History

• Received
  Apr 2012
• Accepted
  Oct 2013