INTRODUCTION

HIV/AIDS is one of the top 10 causes of death and HIV/AIDS is the number one cause of disease burden for women from ages 25–44 years.  In 2010, HIV/AIDS was ranked as the leading cause of disease burden measured as disability-adjusted life years (DALYs) in 21 countries including Haiti.  In Haiti, HIV is transmitted primarily through heterosexual sex (Kershaw et al., 2006). The second mode of transmission is mother-to-child, which represents 6% of reported AIDS cases and may be rising because of increasing infection rates among women (UNAIDS, 2005; WHO, 2001). In addition, unsafe sex between men is believed to account for about one-tenth of reported HIV cases in the region (WHO, 2006). No vaccine exists for HIV/AIDS prevention. Treatment is costly and availability limited in poor countries like Haiti Therefore, control of HIV must depend on the following behavioral changes: abstinence, reduced number of sexual partners, condom use, testing and treatment. These behaviors might be amenable to parental efforts to influence sexual behavior of young Haitian Women. Studies report that daughters who were found to have better communication with their mothers were found to have fewer sexual experiences (Kao, Guthrie & Loveland-Cherry, 2007). Kao et al, (2007) report that sexual communication between mothers and daughters were viewed as a stepping-stone toward the daughters’ sexual health.  Mothers who held conservative attitudes toward premarital sex were more likely to have daughters who rejected permissive sexual behavior and more likely to want committed romantic relationships (Bynum, 2007). In addition, Cunningham and Thornton (2006) stated that parents’ attitudes toward premarital sex, cohabitation, and being single were found to have a strong impact on their young adult children’s attitudes.

Data were found to be limited in addressing parents' contributions to their daughters’ sexual education among women from developing countries like Haiti. Haitian parents were found to be afraid to talk to their kids about HIV/AIDS and Castor (2008)study found that discussions about sexual and reproductive health in Haiti are uncommon and sex education is limited, making transmission of knowledge from one generation to the next difficult. Additionally, according to Adrien et al. (1994) Haitian women generally avoid talking about sexual practices because of their shyness, and cultural conservative and cautious ways. These findings should be replicated and extended.

Archibald (2007) reported that due to the tradition of women keeping silent about matters of a sexual nature, women do not discuss sex at home, in spite of their responsibility to educate their young daughters about sexual health. The traditional roles set for women may place them at risk for HIV because there is a lack of knowledge of, minimal discussion about, and limited understanding of the epidemic. At the same time, Bynum (2007) indicated that mothers who are perceived to be conservative and traditional in attitudes toward premarital sex were more likely to have daughters who rejected permissive sexual behavior and wanted to be in committed and romantic relationships.

The rationale for investigating parental efforts is crucial to seek and use the emergent data to design new HIV/ AIDS educational interventions that are culturally appropriate for young women as well as Haitian women.    The study research question is: what are the perceptions of female students aged 18-24 and nurses aged 30 and over about the influence of parents/mothers on Haitian girls and young women when it comes to learning about sex, learning accurate information about sex and relationships with boys and men, and specifically learning about HIV/AIDS and sexually transmitted infections (STIs).

METHODOLOGY

            The study employed a qualitative research technique, widely used in health research and social sciences to gain better understanding about individuals’ feeling and attitudes (Win good and DiClemente, 1993).  In 2007 this study was conducted online via an established website, www.DIVAhealth.org.  The participants were recruited through a social marketing campaign strategy which included vehicles such as text messages, e-mails, posted flyers and other advertisements throughout the Haitian community in the New York/New Jersey metropolitan area. The researcher flyers were distributed in multiple areas as well emails to different organizations and communities. The participants were a convenience sample of Haitian women over 18 and Haitian nurses. The Haitian nurses were registered nurses working as community and hospital nurses.

There were two focus groups of young Haitian women (n=4) and Haitian nurses (n=3) and each focus group discussion took about 60 minutes. In addition, a total of (n=17) young Haitian women and (n=3) Haitian nurses that participated in interviews with each interview taking between 60 and 90 minutes for a total of 20 interviews. The author conducted all interviews online by chat and emails.   Demographic data were not collected with the exceptions of the age of the participants and country of origin; the author excluded women who were under the ages of 18 and that were not Haitians.  A number of research questions guided the study; Two focus groups were conducted with a young Haitian women (N = 4) and Haitian nurses (N= 3)..  In on-line focus groups women discussed their perceptions about the influence of parents on Haitian women and young women when it comes to learning about sex, acquiring accurate information about sex and relationships with boys, men, and, specifically learning about HIV/AIDS and STIs

RESULTS

          The qualitative research data are presented by research question. A wealth of data was generated. Hence, just selected excerpts are presented. These were selected for being representative of the dialogue generated in the focus groups and interviews. First, the focus group and interviews of the young Haitian women are presented. Secondly, the focus group and the interview data with the Haitian nurses’ results are presented. Next, summary themes are identified.

All data in blocked quotes represent the unaltered words of the study participants. In this manner, we will see how the specific interview questions from the guide shown in chapter 3 produced a variety of comments in focus groups and individual interviews. Within each block quotation, the data that constitutes an emergent theme is bolded, while the goal is to draw from all of these bolded themes a final distillation of just those summary themes that encompass all of the data. These summary themes appear at the end of the presentation of data gathered in response to each question and are presented in a table for each question.

The focus group participants offered the following comments:

Most mothers don’t really talk about sex with their daughters, or if they do, they’re not explicit enough. Haitian mothers love to go around the bush. I think it’s a cultural thing. They may feel embarrassed to talk about it because their parents never did.(Haitian 1)

Haitian parents don’t really sit down and have an educated conversation with their child because they can be very strict and just get to the point and just say don’t do it with stating why and the outcomes of it besides you’ll get pregnant and that finishing college comes first and wait till your married (Haitian2)

For the older generation of Haitian parents (meaning around born 1920-1950’s) they do not know how to talk to their children about sex, relationships. Better yet, most don’t even understand the concept of dating- until you explain it to them. I think that generation; look at the child as a child. They don’t care to be friends with their children or have an open dialogue about things that the child is facing in society. They just lay down a set of rules that you must abide by. Some Haitian parents even try to use threats as a way for the child not to have sex. Telling them that if they have sex before they are married, they will get AIDS. So, lack of education, explanation and dialogue is very common between parent and child. That usually results to the child going to his/her peers or watching TV to get the answers (Haitian3)

An analysis of the findings for the research questions revealed that nurse perceptions of the influence of parents/mothers on Haitian girls and young women fell into two concepts and three themes. The two concepts were 1) limited and no discussions of sex/including HIV/AIDS by the Parents (Mothers) and 2) fear of pregnancy among the daughters. Examples of the noted themes were lack of communication about sex between parents and daughters - sex discussion is taboo/lack of open dialogue between women and most Haitian mothers don’t talk about sex with their daughters. In sum, women did not receive adequate sex education from their parents and those parents were vague about what sex is “for example girls are gasoline and boys are matches".

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Summary Themes Arising From Data with Young Haitian Women

1) parents and family did not talk about sex much or at all, offering no education, perhaps because their parents did not, or from being afraid, or uninformed and needing education themselves
2)  the message was to not have sex
3) adults were not truthful or lied about having sex in their youth, instilling fears of pregnancy
4) sex is not talked about in Haitian culture, or it is not explicit (going around the bush)
5) any talk was confined to abstinence or occurred in a religious context, urging abstinence until marriage, an d no communication of disease risks

Summary Themes Arising From Data with Haitian Nurses

1) mothers do not talk about sex with daughters, or it is not explicit enough, either due to embarrassment or because their parents never did, or they lack the education themselves
2) Haitian parents are strict and direct, lay down rules, do not explain things, may use threats, do not dialogue with those seen as children, and tend to merely warn against pregnancy, not finishing college, while stressing the need to wait until marriage

During the interviews and the focus groups of young Haitian women, this study found the women reported that they had few conversations related to HIV/AIDS and STIs with their mothers as well their peers.  For example, a common comment was “we don’t really talk about HIV, we talk of the act of having sex. HIV is not a topic of discussion unless someone close to us dies of it." It was also reported that there were limited discussions of sex, including HIV/AIDS from mother/parents to daughters. Mothers do not discuss sex because a discussion on a subject of this nature is considered taboo. In addition, it was reported that only young women who were considered “lost” would have such a discussion.

DISCUSSION

This study confirmed that young Haitian women did not receive adequate sex education from their parents/mothers.  Previous reports indicate that young Haitian women who received sexual information from their mothers, reported that to be limited to abstinence prior to marriage and reinforcement of the need to remain a virgin until marriage (Castor, 2008). This implied that a few Haitian mothers provided some semblance of guidance to their daughters without detailed discussion of the issues associated with unprotected sex. In contrast, this study also found that those mothers who sat down and discussed sex with their daughters received positive responses according to the girls.  It was also revealed that mothers who received sex education on sexual and reproductive health themselves (e.g. nurses) were able to inform their daughters of safer sex.  As indicated by Kao et al. (2007) sexual communication between mothers and daughters is viewed as a stepping-stone toward improved outcomes for the daughters’ sexual health. Other findings suggested that mother-daughter relationships, particularly mothers' traditional cultural values, may influence their daughters' decision-making process.

In addition, the studies have found that sexual education of Haitian women often occurred in the context of spirituality and religious beliefs that sex should occurred in the context of marriage.  These principles encourage followers to live a life according to what is written in the Bible and promote abstinence.  Another group of women were making the decision to practice abstinence regardless of religious ideologies but rather in an effort to protect themselves from pregnancy and diseases including but not limited to HIV.  Smith (2004) indicated that when church leaders preach about HIV/AIDS, it is tied to immorality and not being a good Christian. In addition, the same study reported that HIV/AIDS is blamed on sin and sinful ways.  Beck, Cole, and Hammond (1991) reported that an increased rate of premarital sexual behavior when religious background is no longer a strong influence on socialization. Beck et al. (1991) reported that abstinence behaviors are directly related to the level of commitment the individual has to the church versus the influence of social integration, which create a higher level of faith to practice abstinence.

          Similarly, during the interviews and focus group among the young women, it was reported that there was limited sex education or sex conversations among Haitian parents with their daughters. It is considered to be taboo in the Haitian culture to discuss sex and many Haitian mothers refused to talk about sex with their children.  Furthermore, the Haitian community is found to be conservative and traditional about sex and often is not able to talk to their children about sexual health and relationships.  The nurses in the study felt that there is a need for open dialogue because women and adolescent females may be at a heightened risk of HIV/AIDS. The issue of HIV/AIDS and STIS is further complicated by the limited  dialogue in a conservative culture like Haiti’s, where all females are discouraged from discussing sex and are hindered from learning and initiating protective behaviors (Devieux, 2006; Holschneider  & Alexander, 2003).

It was concluded that few Haitian parents are educated to provide a sex education message beyond that girls who have sex become pregnant; therefore they should finish school and wait untill they get married to have sex.

          Arguably, it is important to educate and train Haitian mothers to talk to their daughters about sex. It was reported that Haitian parents who have open discussions of sex with their daughters may be effectively enhancing their daughters’ level of self-esteem and self-efficacy for self-protective behaviors, possibly creating a preventive mechanism to decrease HIV within the Haitian community (Pierre & Fournier, 1999).

The Need for HIV/AIDS Education for Haitian Parents

It is self-evident that a program to fight HIV/AIDS must address the issue of sexual intercourse. Grosskurth, Masha, Todd, Senkoro, Newell et al. (1995) state that in the absence of a cure or vaccine for HIV/AIDS, the most effective strategy to date in decreasing the spread of HIV is education. HIV education must aim to reduce risky sexual behavior as well as to promote condom use. Aarons et al. (2000) state that sexual education intervention programs for young people must be comprehensive and promote sexual abstinence while providing contraceptive information and referrals to appropriate services for sexually active participants. However, Agha (2004) states that Zambian adolescent considered the option of abstinence to be old-fashioned and boring. They interpreted abstinence as meaning that they could not have an exciting social life with a girlfriend or boyfriend. Given these factors, HIV and STIs intervention must, according to Gregson et al. (2004), facilitate and promote HIV avoidance through the interaction of families, churches, businesses and schools acting together to create more favorable conditions in which to adopt safer behavior.

Aarons et al. (2000) indicate that other factors such as peer influence, media influence, and personal social networks are reported to impact adolescents’ decision-making skills. Gregson et al. (2004) report that social groups were found to be positively associated with HIV avoidance, and that young women who were more educated and single had a strong association with HIV avoidance; this was because of their propensity to join groups that function well. In addition, women who were less educated but were part of social group also had a positive association with increased knowledge about HIV. As Holschneider and Alexander (2003) state, it is critical to provide effective HIV education in Haiti as well as in the U.S. They also indicate that prevention that incorporates peer intervention can be beneficial to reinforce safer sex practices because peers speak their “own” language. Peer education has been found to spread information in a clear and easy way-to-understand, which is especially important in HIV education.

This study had a number of limitations: a small convenience sample of women and nurses who had migrated to the US from Haiti, lack of demographic data, lack of data from mothers.  Some subjects lacked time for participation in the complete focus group. This study was unable to address a number of questions important for the prevention of HIV/AIDS in Haitian women.  Thus future studies of Haitian women and their mothers should be directed towards designing an intervention program that would educate mothers and care givers about sexual and reproductive health. The study \should include focus groups and interviews conducted in Haiti—both rural and urban..

Conclusion

This study demonstrated that an online site can be used for qualitative research among Haitian women. Interviews and focus groups with female Haitian students and nurses  confirmed a lack of sexual education of young Haitian women by their mothers and the need for programs to provide them with the information and motivation needed for HIV/AIDS prevention.