HEALTH SERVICES SEEKING BEHAVIOR ON SELF
CARE CONCEPT RELATED HIV AIDS AND STIs AMONG
MEN WHO HAVE SEX WITH MEN
Phenomenology Qualitative Study in Denpasar City
Ns. Nyoman Agus Jagat Raya, S.Kep
Nursing Program, Faculty of Medicine, Udayana University
Bali, Indonesia
Email: jagatraya.bali@gmail.com
Abstract─The transmission of HIV AIDS and STIs dominated through unprotected sexual intercourse. Men who has sex with men (MSM) had a high risk of contracting and transmitting HIV AIDS and STIs. Thus, it increases some cases of HIV AIDS and STIs. The actions were taken to care for themselves independently deemed not optimal without visiting and utilizing health services. This study aims to describing, exploring, and uncovering the health seeking behavior on self care concept related to HIV AIDS and STIs among MSM in the city of Denpasar. In addition, the driving and inhibiting factors MSM seek health care are analyzed. This study uses a qualitative design with a phenomenological approach. The participants were taken from 7 people who selected using purposive sampling methods and data collection techniques with in-depth interviews. Interviews were recorded and analyzed using thematic analysis. Afterwards, the data and test of the data validity were analyzed. Results of this study indicated to the search behavior of MSM to health care services is quite good, merely it was required to give assistances for understanding and mentoring continually so that, the process in independently caring for themselves can be well understood. Views on health cared by the MSM to be are quite good, including health workers, facilities, data storage, and the clinic. MSM motivating factor to seek health care were namely desire, awareness, and call a friend. The inhibiting factors were the lack of information, less activeness, difficulties in obtaining health care, no friends, cost, and fear of test results. One suggestion was given to the nursing community is to be able to reach out to the existence of MSM who have a high risk of HIV AIDS and STIs.
Keywords─ HIV AIDS; STIs; MSM; health services
I. INTRODUCTION
HIV AIDS is an emerging infectious diseases around the world and included on sixth goal in the Millennium Development Goals (MDGs). According to the United Nations Programme on HIV AIDS (UNAIDS) World Health Organization (WHO) regarding the increase in people living with HIV from 2008 to 2010 was as follows:
2008: 32.3 million 2009: 32.9 million, and 2010 : 34 million people [26].
In Indonesia, the number of cumulative to June 2011 recorded cases of AIDS reported cases reached 26,483 and is spread in 33 provinces [9]. Bali as having high susceptibility to HIV AIDS data obtained from KPA Bali with incident cases from January 2012 until August 2012 those as many as 374 cases of HIV and AIDS as many as 432 cases with total mortality by 15 cases. The cumulative data from 1987 to August 2012 reached a total of as many as 3,378 cases of HIV and AIDS cases as many as 3,126 with a total of 490 death cases. Total reached 6,504 cases [14].
Increased HIV AIDS cases are caused by key populations. Men who have sex with men (MSM) entered in the population as key to the spread of HIV AIDS related sexual behavior without using a condom. Frequency of condom use in the past month with regular partners is never amounted to 12%, sometimes 25%, often 26% and always 36%. Meanwhile, last month the frequency of condom use with casual partners or customers those do not have 9%, sometimes 17%, often 27% and always 47% [13].
HIV AIDS is not only a threat to the MSM, but STIs is also a thing that should be wary. This is related to STIs caused by more than 25 pathogenic organisms and viruses that can attack the immune system [11]. STIs will increase due to the high risk of HIV viral entry activity if it remains unprotected sexual intercourse [8]. Although STIs can be treated and in contrast to AIDS has no cure, but STIs will also make a person feel uncomfortable and impact on daily life.
be done by the MSM in order to care for him independently is to seek health care.
Access to health care in the city of Denpasar dominates other districts in Bali and equally accessible in 4 districts, one of which contained PHC (Public Health Center) facilities through VCT. Denpasar city has HIV AIDS and STIs among MSM is higher than other districts in Bali. Recorded from January to September 2012 cases of STIs among MSM in Denpasar on by 120 cases [30], while 96 were HIV reactive after VCT in Denpasar area [29]. Based on this, it is necessary to look at the real research on the health seeking behavior related to the concept of self care among MSM in Denpasar as one of the prevention of HIV AIDS and STIs.
II. RESEARCH METHODOLOGY
A. Design Study
The design in this study used a qualitative research with approach phenomenology approach.
B. Population and Sample
The population in this study was the MSM who live in the city of Denpasar. The sample in this study was called participants and taken from 7 people. The ages of participants were between 15-40 years old with sexual orientation; heterosexual, bisexual, or homosexual. Retrieval method of participant was purposive sampling.
C. Data Collection Procedure
Preparation phase was developed to guidelines for interviews, field notes, and do license with related parties. Implementation phase was done by the introduction of participants and followed by in-depth interviews. Termination phase was done after all the participants validated the results of the interview transcripts.
D. Analysis and Test Data Validity
Analysis of the data was using an inductive process starting point the findings conclusions on the data collected, then concluded in general. Processing data were using thematic analysis, further verified and presented in descriptive form. Stages of data analysis were: 1) the period of data collection, 2) data reduction; 3) presentation of data; 4) conclusion/verification data. Theme selection was determined based on the topics that appear in research, and then the similar topics are grouped in a single theme.
Validity of the study was divided into two, namely internal validity and external validity. Internal validation would be done by implementing the principle researcher credibility, dependability, and conformability for the validity of the data. Transferability was often called external validity. External validity was indicated the degree of accuracy or applicability of research results to the population in which the sample could be drawn [18].
III. FINDINGS
Based on the study, the results showed 10 themes with 33 sub-themes. Response MSM’s knowledge about HIV AIDS and STIs quite good, but not deep. This study was reflected to the theme in the cognitive response to the statement of HIV attacked the immune system, IMS is a genital disease that can be cured; explain media transmission, prevention, treatment, and HIV AIDS connection with STIs.
"HIV AIDS disease that's included in the STIs.
…transmitted by sex." (P4)
Risk sexual behavior perceived of MSM reflected in the sexual behavior theme composed of anal sex and oral sex. Theme inconvenience obtained due to the impact of unsafe sex, perceived pain, and uncomfortable.
"...uncomfortable, while working. When I work, I want to piss or while serving my customer or whatever it is, genital pain was fixed and all. It's also interfere as well, disrupting the work. " (P5)
It affects the attitudes and perceptions of the MSM in performing self care which was reflected in the theme of how to care for them, such as taking care of the cleanliness of the body, keeping away from sexual relations, drug consumption, and routine control. Sources of support were obtained through a friend in the form of advice and motivation.
"…support as possible told to change, only he knows my true character. Could only push him to be on the right path." (P1)
MSM view of the existence of health care services was reflected in the theme of health services consisting of health workers, facilities, data storage, and the clinic. Psychosocial response to the theme in the MSM response when he first visit or utilize health services and it was the perceived fear, depression, and resignation.
"Afraid! Very pounding. Very panic and my face is pale." (P2)
MSM theme motivating factor in seek health care were namely desire, awareness, and call a friend.
"...I want to know the problem. Want to know if I have HIV or not, and for the prevention in the future. Secondly, want to know the health status of myself." (P6)
The inhibiting factors are the lack of information, less activeness, difficulties in obtaining health care, no friends, cost, and fear of test results.
“Only myself have less aggressive, it’s right? …It maybe I
find very busy or lazy or whatever to go utilizing health
“Well, I’m afraid, if I go to public health center, so the result is positive, I afraid if my friends know about the
result, so I do not want that to happen!” (P7)
IV. DISCUSSION
Theme cognitive responses illustrate how far the MSM knowledge about HIV AIDS and STIs. Cognitive responses are part of the structural components of attitude. According to Mann (1969) in Sunaryo revealed that the contents of the cognitive component are the perception, beliefs, and stereotypes of individuals [24]. According Brotosaputro in Supriyanto explained that the education level of the individual is an important factor influencing knowledge. That is, more higher education status of someone, it is more easily to absorb the knowledge and practice in accordance with the knowledge gained [25].
Sexual behavior both anal sex and oral sex is not safe, such as not using condoms would cause a high risk of contracting STIs and even HIV. The data results of research conducted in Atlanta, Georgia gained as much as 73% of MSM do not practice safe sex [16] and in Hanoi, Vietnam 30% did not use condoms of male sex workers [10]. It will have an impact on the sense of discomfort, such as pain and uncomfortable on the genitals and anus. This is consistent with the results of the study in Nairobi, Kenya with the data obtained for 12% of genital pain, 14% burning during urination, 11% of itching in the genital and/or anal [21].
Hygiene care for the body to support self care and self supporting activity daily living (ADL) is optimal. Orem (1985) in Michael Becker believes that his theory is the basis for the health and well being, it is because the client requires more knowledge to maintain the health of yourself and pay attention to each client independently (Becker, 2012). The process of taking care of themselves needs the support of people nearby, like a good friend in the form of advice or motivation. Community involvement can increase feelings of calm and positive self identity among MSM and transgender people, as well as the strengthening of peer norms in the practice of safe sex [7]. In addition to the gay and bisexual more support from friends than family itself [17].
Health services play an important role related of MSM wishes in utilizing health services, including health workers, facilities, data storage, and the clinic. Reason MSM who suffer pain in genital to utilize health care facilities in Kenya by 18% can be reached, the quality of service 15%, 12% recommended by a friend, 10% recommended by health professionals, and the location is close to 2%. By 37% MSM feel comfortable and confidential [21]. VCT and STI clinics can not be separated from the MSM. VCT clinic is a clinic as a process of pre-testing counseling, post-pre-testing counseling and voluntary HIV testing is confidential and even earlier to help people know their HIV status [2]. While the STI clinic is a clinic
that provides clinical and laboratory examinations in cases of genital disorders [22].
Fear, depression, and resignation are psychosocial responses at the first time that felt while visiting or utilizing health services. The first time visit to the health services has a lot of stressors that trigger fear in participants [24]. Physiological responses experienced in case of coping responses that fear is poorly controlled, so that the resulting impact on organs such as heart palpitations, facial tension, general weakness, rapid and shallow breathing, anxiety, and discomfort in the abdominal area and urination [23]. Prolonged depression can cause a person to become discouraged by the desire to end his life and the impact of depression is the inability to deal with stress is more severe [27]. Resignation is the process of adjustment to face demands of the state with conscious, realistic, objective, and rational. Adjustment process according Suharto Heerdjan (1987) in Sunaryo that business admission or behavior that aims to overcome difficulties and obstacles [24].
MSM motivating factor to seek health care are namely desire, awareness, and call a friend. Snehandu B. Karr theory stated that the intention or a person's desire to act in relation to objects or stimulus beyond itself into a predisposing determinant of behavior. In addition, the autonomy or personal freedom (personal autonomy) to take decisions also predisposes one determinant of behavior [19]. According to the theory of Sigmund Freud (1856-1939) explains that consciousness is just a small part of the whole psychic life that illustrate the things that exist in the consciousness and the unconscious. According to Freud the unconscious is contained in the basic forces that drive to do something. According to Kaplan H. et al. explained that the unconscious is limited to seeking the fulfillment of expectations that lead to motivation [24]. MSM tend to be more comfortable talking the status and the problem to friends than parents and friends support a factor that has a relationship to HIV risk [12, 15], so it has an influence on health seeking. Results of research in Kenya on of MSM who experienced genital pain STIs examination obtained 12% of the 137 respondents constitute an invitation from a friend [21].
The inhibiting factors are the lack of information, less activeness, difficulties in obtaining health care, no friends, cost, and fear of test results. In Vietnam is only obtained 11% MSM who use health services and the remaining states are not aware of information about the health care system with a variety of reasons [20]. According to the theory Snehandu B. Karr that the accessibility of information is the availability of information related to actions to be taken by a person and a determinant of behavior [19].
According Maramis, personality traits is the overall pattern of thoughts, feelings, and behaviors that is often used by a person in a continuous adaptation effort against his life [24]. Difficulty in obtaining health services is also described by the WHO that was the location of health services is a part that is often complained MSM, so it needs a focused approach to public health, as well as respond according to the location and the magnitude and trends of the HIV epidemic. This should be based on the WHO program uses a comprehensive service management for MSM, including STI testing and counseling [28].
No friend become the inhibit thing because friends are an important source of support and friends to be a source of information about HIV AIDS and STIs in the form of peer educators [1, 21]. Health costs are considered to be a bottleneck for pricey health care. Therefore, does not little MSM claim to feel satisfactory income from a job as a male sex worker [6]. Fear of test results is an obstacle that is often experienced by MSM. Fear of test results is also described in the research of Magaly M. Blas et al. statement in 2011 regarding the MSM respondents, i.e., "I fear the Consequences of a positive test result" which amounted to 34.4% or 55 of 105 MSM respondents. This research was continued in 2012 in order to fear the results of the test can be done a campaign of support for MSM of stigma and discrimination [5, 6].
V. CONCLUSION AND SUGGESTION Knowledge of MSM to HIV AIDS and STIs can be quite good, it's just still a general nature and not comprehensive. Attitude and outlook towards self care related to MSM sexual behavior. Unsafe sexual behavior would lead to the occurrence of STIs or even HIV AIDS. When the symptoms STIs, the MSM will be a tendency to feel discomfort on him. This discomfort will affect ADL of MSM. This is what will affect the way of doing self care. To support the process of self treatment MSM needs the support of a friend in the form of advice and motivation.
View of the MSM to health care, including health workers, facilities, data storage, and the clinic. While the response when he first time to visit or utilize health services there is a sense of fear, depression, and resignation. MSM motivating factor to seek health care are namely desire, awareness, and call a friend. The inhibiting factors are the lack of information, less activeness, difficulties in obtaining health care, no friends, cost, and fear of test results.
Researcher suggests the community nursing team to be able to do outreach to the MSM who have a high risk of transmission of HIV AIDS and STIs through PHN program. In addition, to policy makers, such as the National AIDS Commission (KPA), NGOs, and governments. For nursing education can be used as the application of the latest scientific foundation in evidence-based nursing and the development of future similar studies.
ACKNOWLEDGMENT
Researcher would like to thank the University of Udayana and NGO of GAYa Dewata Foundation is focused on preventing the spread of HIV AIDS and STIs and has supported the implementation of this study.
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