A Community-Based Approach to HIV Prevention in Rural Guatemala

Community-Based Participatory Research

The current HIV prevention intervention is firmly rooted in community partnership, using CBPR (Neuhauser, Syme, & Kreps, 2014). CBPR encourages the close cooperation of researchers and the local community population in an attempt to create community empowerment and knowledge to improve health outcomes (Amendola, 2013; Guta, Flicker, & Roche, 2013). Through involvement in each stage of the campaign (development, implementation, and evaluation), the priority population recognizes its own capacity to respond to health threats such as HIV (Kakietek et al., 2013; Muturi & Mwangi, 2011; Tynan et al., 2013).

Health Belief Model

Previous scholars have successfully used the HBM to understand sexual behavior and to determine intentions and barriers to HIV testing in many countries (Li, Lei, Wang, He, & Williams, 2016; McCoy et al., 2009; Westmaas et al., 2012; Zhao et al., 2012). The HBM predicts that perceptions of susceptibility, severity, benefits, and barriers (to a behavior) directly influence health-related actions (see Champion & Skinner, 2008). The model also addresses the benefits and barriers to the proposed action that affect the likelihood of taking action. Finally, the HBM includes a cue to action component, conceived as external stimuli (e.g., media campaigns) or internal stimuli that prompt an individual to perform the health behavior (Champion & Skinner, 2008).

Research Questions

Our preliminary research demonstrated the applicability of HBM; however, given the remote location and initial entry into this community, it was necessary to conduct an iterative follow up to facilitate breadth and depth of understanding as well as verify corroboration. Accordingly, the following research questions are proposed:

Data Collection

Data were collected through (1) rapid assessment surveys (RASs) and (2) qualitative interviews. We retained and trained local staff consisting of a local coordinator and four (two female, two male) interviewers who helped with recruitment, conducted in-depth interviews, and administered the RAS. All staff worked for the local health center and were active community health advocates with experience in discussing sensitive topics like HIV. Criteria for study inclusion were (1) heterosexual adults 18 years or older and (2) participants living in Santiago and of Mayan descent. The interview guide used was similar to the one used in Wave 1 (see Orrego Dunleavy et al., 2018) that measured HBM concepts, transmission knowledge, stigma, perceptions surrounding HIV testing and condom use, as well as queries on the campaign logo and message strategy. The RAS was developed by researchers specifically for this project and consisted of 20 questions used in UNAIDS HIV prevention measurement.

Procedure

In public areas populated with the priority population (community centers, church centers, town center square, outside Internet outlets, and the health center), local staff invited volunteers to participate in data collection. Volunteers were not allowed to participate in both the interview and RAS. RAS was quickly administered on location while in-depth interviews were scheduled in the participants’ homes at their convenience.

Participants

The priority population was young adults 18 to 25 years old, recognized by Santiago Health Center as a high-risk group. The priority population also represents a mobile and technologically savvy group that is open to new information and are currently social change agents in their community. Data collection was conducted in the language preferred by the participants (Spanish or Tz’utujil Mayan dialect).

RAS participants (49% males, 47% females, 4% N/A) reported age (M = 22.12, SD = 2.12) and relationship status (49% single, 32% in relationships, 19% married, 1% widowed). Regarding in-depth interviews, 49 were analyzed (49% female, 51% male), as one could not be transcribed. Participants reported faith affiliation (91.7% Catholic or Evangelic, 8% Christian), and employment status (78% were employed, 15% were students, and 6.5% were unemployed).

Data Analysis

Our integrated mixed-method design was used to determine the extent of convergence between quantitative and qualitative data in order to expand our understanding of HIV prevention among indigenous Mayans. The interviews and RAS responses were translated and transcribed into English. NVivo 9.0 was used to sort and analyze interview data. Constant comparative analytical method was used to identify interview themes (Corbin & Strauss, 2008), guided by HBM. Descriptive statistics of RAS data are reported. The common concepts described below provide a comprehensive and an insightful analysis of the priority population.

Perceived Susceptibility

Results confirmed Wave 1 findings, indicating that concurrent partnerships, commercial traveling, premarital sex, and availability of brothels and prostitutes in Santiago encourage risky sexual behaviors. First, the interview participants acknowledged that many engage in multiple and concurrent sexual partnerships. One of the reasons is lack of employment opportunities for men in Santiago, and when “the man goes to work, the man has two or three partners” (female). Moreover, if a married man is not satisfied sexually with his wife, he can frequent brothels, or seek other women, which is acceptable in the community, “. . . for society it is normal that men go to these places [brothels] because they are men and simply they have necessities” (female). This behavior places men at high risk for HIV infection, because “they [men] do not think about carrying condoms” (male).

Next, many participants were unaware of their risk for acquiring HIV, and they did not identify themselves with the associated risks, “I am with my friends, the time I share with them is not one where I can be infected” (female). One of the explanations was the lack of information about HIV in the community, because talks about sexual relations, including STDs and condoms, are not culturally acceptable, “In our culture, we are not allowed to hear . . . information on condom usage, people think it is vulgar” (male). Additionally, according to participants, youth engage in sexual relationships as early as age 10. Unsafe sexual practices among youth was attributed to lack of sexual education. One female participant stated, “Currently I would say many young people use technology wrongly and so they are promiscuous . . . they start to have sex at age 14 or 15.”

Finally, minimal sexual education and a reluctance to discuss consequences of unsafe sexual practices contributed to mixed HIV knowledge among the local community. Similarly, RAS findings indicated that 23% of participants believed that an individual can contract HIV from mosquito bites, 29% stated HIV can be transmitted via meal sharing with an infected individual, 47% believed in mother-to-child transmission during pregnancy, and 22% reported mother-to-child transmission via breast-feeding (see Table 1). Thirty-two percent of RAS participants possessed no knowledge of HIV transmission. A female interviewee commented on the low level of HIV knowledge in the local community, “I think there are many people that still don’t know anything about it, but more than a few have a general knowledge, but not the majority.”

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Table 1

Rapid Assessment Survey (RAS) Results

RAS: HIV Knowledge	% Yes	% No	% Don’t Know	% Refuse	% N/A
Do you think being faithful to one sexual partner who does not have HIV can reduce the risk of HIV transmission?	51	4	31	5
Do you think you can reduce the risk of HIV transmission by using condoms?	44	27	24	6
Do you think that a healthy-looking person can be infected with HIV?	41	23	36	1
Do you think you can become infected with HIV from mosquito bites think?	23	34	41	3
Do you think you can get HIV by sharing a meal with someone who is infected think?	29	38	32	1	1
Do you think that a pregnant woman infected with HIV can transmit it to her child?	47	10	40	4
Did you know if a woman infected with HIV can pass the virus to her child through breast-feeding?	22	51	26	2
RAS: Condom Perceptions	% Agree	% Disagree	% Don’t Know	% Refuse
Can using condoms cause men physical pain?	7	20	20	23
I could talk to my partner about condoms.	39	23	28	11
It would be easy to make my partner use condoms.	22	22	45	12
I could use condoms without ruining the romantic mood.	17	21	51	12
If my partner didn’t want to use condoms, I could refuse to have sex.	22	31	33	14
I could purchase condoms without feeling embarrassed.	30	25	26	20
I could comfortably talk about condoms with my friends.	44	22	25	10
I feel comfortable talking about HIV/AIDS with people in my community.	54	15	30	2
HIV Testing Perception	% Yes	% No	% Don’t Know	% Refuse
Is it possible in Santiago for someone to get a confidential (no one will know the results unless you want them to know) test to find out if they are infected with HIV?	45	13	37	6
Have you ever been tested for HIV?	25	71	1	3
Would you feel comfortable getting HIV tested here in Santiago Atitlán?	43	15	39	4
Stigma	% Yes	% No	% Don’t Know	% Refuse	% N/A
If a member of your family became ill with HIV, the virus that causes AIDS would you want it to remain a secret?	4	63	29	5
Would you be willing to share a meal with a person you knew had HIV or AIDS?	24	41	33	2	1

Perceived Severity

Results confirmed our Wave 1 data regarding perceptions of high medical consequences, and stigmatization against persons living with HIV/AIDS (PLHIVs), but also revealed additional severity themes (see Table 2). Participants viewed HIV as a serious community threat affecting not only the life of an individual but also his or her family. Many interviewees expressed fear discussing HIV as an incurable deadly disease, which may heighten stigma around those living with HIV. RAS results confirmed that only 24% were willing to share a meal with a PLHIV. However, 63% of participants reported they would support a family member who became infected with HIV. The collectivistic character of the community could explain this, as family and caregiving to family members are highly valued.

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Table 2

Perceived Treat: Perceived Susceptibility and Perceived Severity

Theme	Illustrative Respondent Narratives
Perceived susceptibility
Risky sexual behavior	“I think if they [men] have multiple partners they won’t really use condoms, it really depends if they use or not.” (Female)
	“I think brothels here and prostitutes are more exposed to being infected. . . . Many commercial workers that travel to the capital are also at risk.” (Male)
Reluctance to discuss personal vulnerability	Question: “Is the environment in which you and your friends surround yourselves in, a risk? Why or why not?” Answer: “No because if I am with my friends, the time I share with them is not one where I can be infected.” (Female)
	“I think, yes. Because it can be that one member of my family is not informed enough to protect themselves, because as part of the youth you do not have enough information.” (Female)
Early sexual onset	“[In this community, young men start to have sexual relations] in their adolescence, about age 10; [young women start to have sexual relations] the same, in their adolescence.” (Female)
	Question: “In this community, at what age do young men start to have sexual relations?” Answer: “11 years.” (Male)
	“I would say [men] starting form 13 or 14 years old, they are curious so they start early; I would say [women] the same, age 13 or 14” ( Female)
Mixed HIV knowledge	“Personally, I think that HIV is the name of the disease, but AIDS is the actual disease once contracted by the person. . . . I think there are many people that still don’t know anything about it, but more than a few have a general knowledge, but not the majority.” (Female)
	Question: “What is commonly known about the transmission of HIV/AIDS?” Answer: “Well the common thing is sexually transmitted, but doctors say it can also be transmitted through flies and moths.” (Male)
Perceived severity
High medical consequences	Question: “Are there barriers to get tested in Santiago?” Answer: “I think no, except maybe fear of finding out the truth.” (Female; see more quotes in “barriers/fear” category)
	“There is no treatment or cure so people really do feel this fear.” (Male)
	Question: “Do you know the difference between HIV/AIDS?” Answer: “I have heard stories of families dying because of the disease so we need to know more.”(Male)
Negative impact on the life	“Yes [HIV/AIDS is a health issue that is important here in Santiago] because when a person has AIDS they need costly treatments and they put others at risk.” (Female)
	Question: “Do you think HIV/AIDS is a health issue that is important here in Santiago? Why or why not?” Answer: “Yes because there have been families that have passed away because of disease.” (Male)
Stigma against PLHIV	“If someone has HIV/AIDS people think that they are promiscuous.” (Male)
Stigma related to condom use	Question: “What would you think of a person who has a condom?” Answer: “Well I would think that the person is very lustful, and they look for people to have sex with often but at the same time they are protecting themselves.” (Male)

NOTE: PLHIV = person living with HIV/AIDS.

Perceived Benefits

Results converged with Wave 1 data regarding condoms and HIV testing (see Table 3). Some interviewees reported that many people used condoms for family planning purposes due to cultural norms and religious beliefs, “I think [people use condoms] to not prevent the disease; it is more so that the woman will not get pregnant” (female). While others did recognize an HIV prevention role, “For me, people use condoms more to prevent HIV/AIDS because they do not want to get infected” (male). Regarding HIV testing, RAS participants reported a moderate level (43%) of comfort in obtaining an HIV test in their community.

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Table 3

Perceived Benefits and Barriers

Theme	Illustrative Respondent Narratives
Perceived barriers
Desire for children	Question: “What are some common reasons that couples do not use condoms?” (Repeats question)
	Answer: “It’s like saying, well they already have in mind to have sex or to have a family.” (Male)
	Answer: “Because they are planning to have a child.” (Male)
Embarrassment	“The biggest barrier is embarrassment and lack of information.” (Female)
	“I think don’t think there’s a bigger barrier than embarrassment and being worried about what other people are going to say, that might be the biggest barrier.” (Male)
Gender roles	“We live in a society where a man having sexual relations before marriage is accepted and normal but with a woman they are called a prostitute, or easy women. Our society and culture have a “macho” mentality.” (female) “. . . and third [barrier is] the mentality that a man is superior.” (female)
	“For a man to be sexually active, people don’t care, in comparison to a woman I think because of the cultural influence and because of religion that a woman is weak, she is more discriminated against.” (Male)
Lack of dialogue	“Not to 100% there is a huge majority that do not know about this topic. For older adults, this topic is taboo and do not like talking about it in public. Young adults talk more because they have the Internet but there is a huge majority that are uninformed.” (Female)
	Answer: “What we’re talking about now is seen as taboo and no one wants to talk about it but thanks to the new levels of education that we have, now we are talking more about it so that we have a better understanding, I think that helps a lot, knowing how to prevent it. It’s the mentality, not wanting to use it and embarrassment also.” (Male)
Religious beliefs	“Religion may be a barrier because some religions say that you should only have sex when you are married.” (female)
	Question: “What are some common reasons that couples do not use condoms?” “Answer: “First because maybe they don’t have a sexual experience or a proper education related to sexual relationships, religion is a huge part of this, religion influences sexuality.” (Male)
Low HIV testing rates	“They are not easy to access [testing facilities] because of the culture and the embarrassment.” (Female)
	Question: “Are there barriers to get tested in Santiago?” Answer: “No, it is not easy to get tested because people get scared or they get scared to ask.” (Male)
Fear	“Barriers would be embarrassment and fear.” (Female)
	Question: “Is there a barrier to acquire condoms?” Answer: “Embarrassment, people who fear being judged has always existed, if they see you buying condoms, people think you are addicted to sex. Even the people that sell, if you are buying condoms constantly you will be judged.” (Male)
Pleasure reduction	“The first barrier [to use condoms] is that it reduces pleasure . . . ” (Female)
	“Well, it depends on the people. Many times I hear that people do not like them [condoms] because it is less satisfactory that not using it.” (Male)
Local customs	Question: “Is there a barrier to acquire condoms?” Answer: “In my case yes, some barriers exist. Authorities will not allow young adults to buy condoms.” “Pharmacies will require documentation from minors.” (Male)
Perceived benefits of prevention
Pregnancy prevention	“I think [people use condoms] to not prevent the disease no, it is more so the woman will not get pregnant.” (Female)
	Answer: “They use it [condoms] more to prevent pregnancy. They do not use it to prevent disease.” (Male)
HIV prevention	“I think it is the only method that tried to prevent disease of HIV/AIDS even if it does not work 100% of the time.” (Female)
	Question: “So you would say that people usually use condoms when they are trying to plan for the family rather than to prevent and sexually transmitted disease?” Answer: “For me, people use condoms more to prevent HIV/AIDS because they do not want to get infected.” (Male)
Condom accessibility	Question: “Where are they available?” Answer: “In the pharmacies, in the Health Center, but it is hard for people to ask for them.”
	Question: “Are there enough available?” Answer: “There are not enough to protect the entire community.” (Female)

Perceived Barriers

Wave 1 data were also confirmed regarding cultural barriers: desire for children, embarrassment, gender roles, lack of dialogue, religious beliefs, and low HIV testing rates (see Table 3). Additionally, results identified “pleasure reduction” as a barrier to condom use, and “fear” of positive results as a barrier to HIV testing. Lack of knowledge was identified as a key contributor to these assumptions. Thus, less than half of RAS participants (44%) believed in condom efficacy for HIV prevention. Consequently, only 22% would refuse to have sex if his or her partner did not want to use condoms, while 31% would still have sex, and 33% reported being unsure.

Cultural factors had a strong influence on decision-making processes in the local community. A primary influencer in relationships is machismo, where a man exerts his superior role within relationships. One female participant acknowledged, “The ‘machismo’ still exists, men want to impose their authority with a woman, and they don’t listen to the woman if she wants to protect herself. . . . He ignores the possible dangers of having sexual relations.” Machismo is also reflected in males’ primary concern for pleasure, in which they perceive they “may feel less satisfaction when having sex while using condoms” (female). Furthermore, interviewees acknowledged religion as “a huge part of sexual relationships” that “influences sexuality.” The church promotes having big families encouraging married couples to reproduce. The use of prophylactics to impede natural reproduction is considered sinful; subsequently, many local people do not use condoms. A female participant reported, “Because many people here are religious and using condoms is a sin so they will frown on this method.”

Cultural and religious factors influenced the lack of dialogue about condom use, efficacy, and purchase. Some young adults discussed these topics and sought information via the Internet, nonetheless, majority of young people were uninformed, “I think here in Santiago, no one talks about AIDS . . . in school and in the home . . . no one tells you directly that you have to use a condom . . . or how to use condoms” (male). Only half of RAS participants demonstrated some level of comfort to discuss condoms with their friends or community members: 44% could comfortably talk with their friends and 54% felt comfortable talking about HIV/AIDS with people in the community. Only 39% of the survey participants would talk about condoms with their partners, and only 22% agreed that it would be easy to make their partners use condoms. Cultural norms and existing stigma perpetuated embarrassment associated with purchasing condoms. Only 30% of RAS participants could purchase condoms without feeling embarrassed. A male participant stated, “I would be embarrassed [to buy condoms], it is like when you commit a sin.” Other participants noted, individuals who buy condoms fear stigmatization or being considered as sex addicts. Additionally, religion denounces premarital sex; therefore, unwed individuals are embarrassed to obtain condoms.

Only 25% of RAS participants reported getting tested for HIV. In addition, some interview participants were unfamiliar with the availability of HIV testing centers, with some participants reporting concern about accessibility. One female participant commented, “I don’t know about those. I would imagine you can get tested in clinics or labs . . .” Anticipated stigma and fear of positive test results were also barriers. One of the male participants shared a story he observed at a testing center, “A group of young adults wanted to give the tests . . . and nobody wanted . . . to take the test. . . some were embarrassed and others were scared.”

Cue to Action

Wave 1 data were also confirmed regarding effective channels for the HIV prevention campaign, including a community-designed logo, a slogan, and multimedia outreach stressing use of radio and social media platforms (see Table 4). Regarding radio, “Well here in Santiago, almost half of the people don’t have access to television, and I would say radio first.” Social media was also suggested as an effective channel for reaching young people. Participants approved of the current campaign slogan encouraging sexual personal responsibility. A female participant commented,

My message would be that we all have a responsibility to take care of our health, if we are knowledgeable of our actions we will have a rich and healthy life, if we ignore these messages, we will be negatively affected.

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Table 4

Cues to Action

Theme	Illustrative Respondent Narratives
Media usage	“This information can be transmitted through radio, where else should we take these messages? Television, maybe in a television program where you could explain this to everyone. Perhaps also in social media because the majority of young people are connected.” (Female)
	Question: “This information can be transmitted through radio, where else should we take these messages?” Answer: “I would say through television as well and take this information to schools that would be an effective method. Social media would also be very effective.” (Male)
	“Radio is a great way to transmit information and television as well. I would recommend to use long interviews of half an hour long would be a longer more extensive way to give information. Small radio and television spots would help a lot. Giving lecture in educational centers would also help. Transmitting in another language would be for older people, nowadays everyone knows Spanish it is the most common. Social media is a huge medium, making a page about positive sexual education would be good as well.” (Male)
Message frame	“My message would be that we all have a responsibility to take care of our health, if we are knowledgeable of our actions we will have a rich and healthy life, if we ignore these messages, we will be negatively affected.” (Female)
	“My message would be to inform yourself on the topic and to learn more. I think abstinence is the best and most natural alternative to preventing disease.” (Female)
	Question: “What specific topics and concepts should be discussed?” Answer: “First, it would be the prevention, then the risks, and finally the diseases that can be contracted.” (Male)
Type of media campaign	“The message would be more focused on the young adults because they are more at risk, to have clear and concise messages, punctual messages where a young person can understand their value.” (Female)
	Question: “This information can be transmitted through radio, where else should we take these messages?” Answer: “Activities would be to identify examples using projectors to understand HIV better. The topics of conversation would be how to have sexual relations, at what age a couple should begin, how to use condoms, talk about injections that women get every month. A general message for the population of Santiago.” (Male)
Logo	“Yes, I identify with this logo and the symbol of the coyotal, which represents our community and our culture. The coyotal represents us a lot.” (Female)
	Question: “What do you think about these logos? The quality? The design?” Answer: “Well, for me the more favorable one would be the first one, because it reflects love of your body, or my body, it reflects love and has a strong message, “my body my responsibility” and it also reflects the coyotal, which is a symbol of the community.” (Male)

Additionally, participants confirmed that intervention messages should also promote abstinence and monogamy. Furthermore, due to cultural norms of labeling sex talk as taboo, many respondents suggested interpersonal dialogue and use of education centers to discuss such sensitive topics. Finally, when asked about the logo, participants approved of the logo, “because it reflects love, . . . and the coyotal, which is a symbol of the community, and [it] has a strong message, “my body my responsibility” (male). Some interviewees offered some design improvements, including use of the Lake Atitlán image to reflect the pride for the local society.