Introduction

In recent decades, the human immunodeficiency virus (HIV) has become a major public health problem, especially in low- and middle-income countries. Approximately 37 million people live with HIV worldwide; in addition, it is estimated that 35 million people have died from HIV-related causes. Regarding Mexico, 75 thousand cases of HIV have been reported from 1984 to the first quarter of 2018, according to the World Health Organization and the Ministry of Health, 2018 ^(1,2).

Migration is the movement of people to another country or state. It is estimated that 3.3% of the world's population (247.7 million) leave their country in order to obtain better living and economic conditions and to avoid factors that endanger their physical and psychological integrity. The situation of migrants in transit is dangerous, it is considered a public health problem due to their lack of opportunities, lack of records for medical care; during 2015 more than 5,000 women, men and children lost their lives on migratory routes in all countries ⁽³⁾.

The situation of vulnerability faced by migrants brings with it emotional changes that can facilitate or hinder their adaptation during the migration process, which can translate into behavioral or learning changes, such as the acquisition of risky sexual behaviors that expose them to sexually transmitted diseases such as HIV ⁽⁴⁾.

During transit, migrants face difficulties such as living in shelters, living with other migrants, exposure to substance abuse and exposure to risky sexual behavior, among others. Self-esteem has been identified as a basic self-perception that generates attitudes where the person gives himself a value of self- respect that allows him to face all kinds of situations. According to the evidence obtained, self-esteem in the migration context may influence decision making for the practice of sexual behaviors, which may lead it to be a protective or risk factor ^{(5 6-7 8)}.

Risky sexual behavior is defined as various risky sexual behaviors and practices with a tendency to provoke personal and partner eroticism. In the same sense, risky sexual behavior for the migrant population can be considered as the exposure of the individual to circumstances that may cause harm to his or her health or to the health of another person, indirectly or directly ⁽⁹⁾.

Therefore, it is considered important to conduct a systematic review with the aim of learning the results of studies that evaluate the relationship between self-esteem and risky sexual behavior in migrants.

Methodology

The study protocol was performed according to the recommendations of PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) ⁽¹⁰⁾.

We included studies of descriptive, correlational, predictive and association design, in English and Spanish. Inclusion criteria were: studies conducted in migrant population, including all migrants from all countries, men or women, of all ages. Repeated articles or those that did not meet the eligibility criteria were eliminated from the search results.

The search was carried out in the following electronic databases in the health field: PubMed, EBSCOhost, Scopus, Web of Science and SciELO Citation Index. For the search strategy in the aforementioned databases, the following keywords were established: self-esteem, sexual behavior and migrant; for their search, Descriptors in Health Sciences (DeCS) and Medical Subject Headings (MeSH), synonyms, related terms, orthographic variation, abbreviations and wildcards were used, combined by means of the Boolean operators AND, OR and NOT (See Table 1). The period of the searches was from October 1, 2018 to December 1, 2018.

A total of 320 primary articles were obtained, 17 from EBSCO Host, 143 from PUBMED, 107 from SCIELO Citation, 10 from SCOPUS, 42 from Web of Science and 1 from Google Scholar for gray literature; the elimination of duplicate articles was performed with the END NOTE software, 22 were eliminated.

When screening by title, 119 articles were excluded because the variables contained in the title were not related to the topic; when screening by title and abstract, 31 articles were eliminated because they did not address the migrant population completely; when full-text screening was performed, 72 articles were eliminated because the method used did not correspond (non-migrant population and study objective with a variable other than self-esteem); when the critical reading cards were made, 71 articles were eliminated because the study was not related to the objective of the review; the result was 5 articles to review (see Figure 1). It should be noted that the screening performed always considered the variables of interest; also, the quality of evidence was evaluated using the STROBE (Strengthening the Reporting of Observational Studies in Epidemiology) tables, which allowed the identification and evaluation of the methodology and structure of the selected articles. Cards were also used to document the critical reading (See Figure 1).

Source: Prepared by the authors.

Figure 1 PRISMA Flowchart, n=320 articles.  

The articles (studies) assessed were published between 2001 and 2017 and were descriptive, correlational and/or longitudinal, cross-sectional design studies. The sample of participants ranged from 146 to 408 migrant adolescents and adults. In general, the characteristics of the populations addressed in the different studies were male and female migrants, aged between 11 and 58 years (See Table 2).

Results

The articles selected to answer the research question of this systematic review were five, of which one has a high level of evidence and four have a medium level of evidence. For practical purposes, taking as a reference the main objective, which is to know the relationship between self-esteem and risky sexual behavior for HIV in migrants, we were able to group the results of interest shown below. In the selected articles, the sample is 1,543 migrants, men and women, adults and adolescents, aged between 11 and 58 years old. Regarding the resolution of the objective, the relationship between self-esteem and risky sexual behaviors for HIV in migrant population is not clear; the results found in the analysis of the articles show that higher self-esteem predicts risky sexual relations, lower probability of using condoms consistently (β = -40, p <.01) ⁽¹¹⁾. For their part Pack, Crosby, & Lawrence ⁽¹²⁾ emphasize that there is similarity in the practice of unsafe sex and self- esteem (β = 81 0.17, p < .001), they refer that self-esteem is associated with risky sexual behaviors.

Ganczak, Czubińska, Korzeń, & Szych⁽¹⁵⁾ reported that low self-esteem in migrants is associated with a higher probability of sex and unsafe sex with a casual partner (OR = 1. 82); similarly, McCoy, Shehadeh, Rubens, & Navarro ⁽¹³⁾ reported that there is a negative correlation between self-esteem and unsafe sex, as well as greater episodes of unprotected vaginal sex and unsafe sex with casual partners (r = -0.09, p = 0.032).

Inconsistencies were identified with the results because it would be expected that according to the concept of self-esteem, if high self-esteem is present, it would represent a protective factor for risky sexual behaviors ^(14,16,17), which would mean a positive relationship in the reduction of risky sexual behaviors; however, results with low self-esteem and high self-esteem that are related to sexual risk behaviors were identified.

Discussion

It is important to keep in mind that the inconsistency in the results regarding self-esteem as a protective or risk factor for sexual behavior can be explained by the fact that low self-esteem translates into dissatisfaction with oneself and attitudes of rejection, some manifestations of which are not daring to say no to any sexual request for fear of not being valued or taken into account by their partner. On the other hand, high self- esteem expresses the feeling of being good enough, the individual feels that he/she is a person of value capable of engaging in sexual behaviors; however, given the lack of knowledge of prevention methods, they have more unsafe sexual practices characterized by multiple sexual partners, unprotected sex and sexual relations with prostitutes ^(5,16).

While it is true that self-esteem is a personal factor, it may be related to the migrant's age, gender, schooling, low risk perception and poor knowledge of sexual behaviors. Given this situation, nursing professionals suggest continuing to study the concept of self-esteem and risky sexual behaviors for HIV in the migrant population due to their high vulnerability. International studies show the opportunity to identify strategies to address this population in order to reduce the number of new HIV cases ^(18,19).

Conclusions

There is inconsistency in the evidence on whether self-esteem is a protective or risk factor for migrant sexual behavior, because with higher or lower self-esteem, risky sexual behaviors are presented; however, it is important to note that migrants are in a process of emotional and attitudinal instability that can lead them to experience the main risky sexual behaviors that affect this population, such as unsafe sex, not using condoms systematically, and having multiple sexual partners. It should be noted that the studies analyzed do not mention risky sexual behaviors for HIV, so it is proposed that we continue to address this vulnerable population that is in constant change and that multiple factors influence their decision making and behavioral changes.

Conflicts of interest

The authors declare that they did not have any conflict of interest.

Financing

This literature review was not funded.