Achieving peace and harmony in life: Thai Buddhists living with HIV/AIDS
Correspondence: Quantar Balthip, Public Health Department, Faculty of Nursing, Prince of Songkla University, Hatyai, Songkla 90112, Thailand. Email: email@example.com
This study aimed to reveal the process of achieving peace and harmony in life by Thai Buddhists living with HIV/AIDS in Southern Thailand. Data were gathered from 28 Thai Buddhist participants aged 18 years or older, who had lived with HIV/AIDS for 5 years or more. Purposive, snowball and theoretical sampling techniques were used to recruit the participants. Data collection, using in-depth interviews, was carried out over a 7 month period between 2011 and 2012. Grounded theory was used to guide the process of data analysis. Two categories emerged to describe the core category ‘Achieving Peace and Harmony in life’: (i) understanding and accepting that nothing is permanent and (ii) living life with contentment. Findings are valuable for health professionals in enhancing peace and harmony for their patients.
HIV diagnosis is a life-altering event that affects all dimensions of life and impacts on relationships, roles and lifestyles. People living with HIV/AIDS inevitably face high levels of insecurity and suffering because the diagnosis causes physical changes[2, 3]; psychological trauma; insecurity; uncertainty[3-5]; and losses of autonomy, self-esteem, friends, future goals and hope.[6, 7] Although the antiretroviral drugs regimen can extend the lives of people living with HIV/AIDS, they have to deal with the stigma and rejection associated with the disease. This situation erodes their sense of self, changes the perspective of their lives and affects relationships with others. Suffering might lead people living with HIV/AIDS to commit self-harm, including suicide.
In addition, the antiretroviral drugs regimen requires careful management and monitoring.[9, 10] In order to enhance the success of self-care and disease management, adherence to restrictive regimens is crucial. Frequent medical appointments and costly medications to promote a sense of well-being and reduce the potential for drug-resistance over time are also necessary. Although advances in medication have changed the prognostic status of HIV/AIDS from that of an early death to that of a chronic illness, deaths resulting from HIV/AIDS still occur and the rate of mortality is daunting.
In Thailand, the Bureau of Epidemiology, Ministry of Public Health (MOPH) reported that the Thai scholars estimated that by November, 2012 there were more than 1,200,000 Thais infected with HIV and they were in the asymptomatic period. Most of those infected with HIV were in the 15–45 years old age group (85 %). In the same year, the Bureau of Epidemiology, Ministry of Public Health (MOPH) received reports from many public hospitals which indicated that 276,947 Thais living with HIV/AIDS were sick and 65% among those who were ill were in the 30–44 years old age group.
In addition to living with life-threatening illness, all over the world including Thailand, people living with HIV/AIDS have to make extensive adjustments in order to find harmony in their lives.[12, 13] In Thailand, over 90% of Thai people are Buddhists and Buddhism has been integrated into Thai society for more than 2000 years. Hence Buddhism has a strong influence on Thais' way of living and their perspective of life. According to Buddhist teaching, life is a combination of mind and matter (body) and a good mind reflects via a good body. For example, when people have a calm mind they have the ability to gain understanding and insight into the truth, suffering and the impermanence of life. This leads to feeling free from need or craving, and gaining peace. Little is known about how people in Thailand with HIV/AIDS achieve the process of harmony in their lives. The purpose of this study is to gain better understanding of the process of achieving peace and harmony in life of Thai Buddhists living with HIV/AIDS in Southern Thailand and to identify the influences of Buddhism on the life balance of the people. The one principal question at the outset of this study was: How do Thai Buddhists living with HIV/AIDS in Thailand develop their harmony?
The Strauss and Corbin approach to grounded theory was used to explore the process of achieving peace and harmony in life of Thai Buddhists living with HIV/AIDS in Southern Thailand.[16, 17] Grounded theory methodology is a qualitative research design in which the researcher aims to generate theory that is grounded in data.[18, 19] Theory is generated on the basis of data that are systematically gathered in naturalistic settings, and concurrently analysed.[12, 16, 17, 20] Grounded theory plays a significant role in areas in which little work has been done. Thus, one of the major uses of grounded theory is for preliminary, exploratory and descriptive studies.
In the initial stage of data collection, purposive sampling was employed through gatekeepers; nurses, health volunteers and leaders of HIV/AIDS groups. The gatekeepers arranged the time and place for the researcher to have an opportunity to talk about the study to persons living with HIV/AIDS who met the inclusion criteria of the study. The inclusion criteria were persons who (i) had lived with HIV/AIDS for 5 or more years; (ii) were aged 18 years or older; (iii) were Buddhists; (iv) were able to communicate in the Thai language; and (v) were willing to participate in this study.
Snowball sampling to search for further participants was also employed. At a later stage of data collection, participant selection was based on theoretical sampling where participants were sought who had particular life experiences that could contribute to more in-depth understanding of concepts identified from previous interviews. Sampling and analysis occurred simultaneously as the study progressed.[12, 21, 22] Sampling continued until theoretical saturation or category saturation was reached, that is, when participants were saying nothing new about the concepts being explored.[22, 23] A total of 28 participants were interviewed.
Data collection methods
Data were gathered mainly through in-depth interviews conducted in Thai by researchers. Both unstructured formal interviews and informal interviews were used. Multiple interviews were carried out with 25 of 28 participants in order to strengthen data analysis. The researchers were unable to contact two participants for follow-up interviews because they went to Bangkok (Thailand's capital city) to continue their studies. Another participant was interviewed when data analysis was close to theoretical saturation. As no new information emerged from the first interview with her, a second interview was not undertaken. Formal interviews were audiotaped and transcribed verbatim, whereas field notes were written on informal interviews. The duration of each interview ranged from 40 to 120 min. Participants were approached with two main questions: (i) What is going on in your life as you deal with this disease? and (ii) what helps you to move on in your day-to-day living? Probes were used to clarify responses. For example, when a participant said that ‘I have to let go my suffering in order to live well in this situation. If I keep thinking about my previous suffering, I could not live’, the researcher asked ‘How can you learn to let go? Who teaches you?’
Approval for the study was granted by the Human Ethics Committee of the Faculty of Nursing, Prince of Songkla University, Thailand. All participants were informed of the purpose of the study and signed consent forms. The time and location of interviews were decided according to the convenience and comfort of participants. Data were collected between 2011 and 2012.
In this study three types of coding were used—open, axial and selective coding—as guided by Strauss and Corbin.[17, 24] The aim in open coding was to code, identify, categorize and compare phenomena according to their properties and dimensions.[16, 17] Each transcript was read carefully and the key words underlined. The data were broken down into discrete events, and then each event was coded. Codes that shared common characteristics were grouped into concepts. Similar concepts were grouped together in order to develop categories. In axial coding, the data were put back together in a different way through categorizing them and making links between a category and its subcategories guided by the paradigm model of conditions, action/interaction and consequences. In selective coding, the core category, which presents the main theme of the research, was identified.[17, 24, 25] The process of selective coding used techniques such as writing a storyline, making use of diagrams, and reviewing and sorting of memoranda in order to facilitate identification of the core category and integration of concepts. The process of constant comparison continued until a theory with sufficient detail was generated and outlined the process, conditions of, and actions/interaction necessary for achieving peace and harmony in life of the Thai Buddhists living with HIV/AIDS.
The ages of the 28 participants (23 females and 5 males) ranged from 18 to 54 years with an average age of 31.5 years. At the time of data collection, 20 participants had partners and 13 of these partners were HIV infected. Eight participants were widowed or separated. Nineteen participants reported having children, and four of these children had HIV. The period of time since being diagnosed with HIV/AIDS ranged from 5 to 15 years. The participants' educational levels ranged from completed primary school to a 4 year bachelor's degree. Twenty-four were employed in a variety of jobs including working on volunteer basis with HIV/AIDS support groups (n = 7), construction (n = 2), unskilled workers in a factory (n = 2), rubber plantation (n = 5) and casual manual workers (n = 8). Four participants were unemployed.
Twenty-five participants were infected with HIV through sexual intercourse, one from drug use and the other two participants did not know the source of the infection. All participants had experienced opportunistic diseases such as pulmonary tuberculosis and meningitis. At the time of data collection, 24 participants reported taking antiretroviral drugs.
Core category: Achieving Peace and Harmony in Life
The core category found in this study was Achieving Peace and Harmony in Life. The key categories in the process of achieving peace and harmony involved understanding and accepting that nothing is permanent and living life with contentment. Living life with contentment involved living with: equanimity, self-sufficiency, care, loving kindness, compassion and a sense of gratitude.
Understanding and accepting that nothing is permanent
The main condition that enhanced peace and harmony in life of the participants occurred when they opened their mind to understand and accept that nothing is permanent. Thai people always say ‘nothing is permanent’, particularly when they are faced with the experience of loss. This notion can explain difficult questions. For instance ‘Why do I have this disease and become ill?’, and ‘Why do human beings die?’ This notion can be explained by saying that dying and death are the truths that every human being will encounter sooner or later. This answer can comfort and lead the participants to accept their illness more easily because it is a truth of life. As one participant said:
After living with this disease and facing the dying experience, I understood that being born, getting old, being sick and dying is a normal cycle of human beings and natural experiences. In the past, I hardly thought about dying. But now I could see the reality of life. Nothing is permanent. We should learn to let go, then we can obtain inner peace.
In addition, once they possessed the belief that nothing is permanent, they felt comforted. This helped them to accept their situation. They realized that the suffering experienced now would later disappear. By the same token, when experiencing happiness, they were conscious that the feeling would sooner or later vanish. By accepting that nothing is permanent, participants were able to live in harmony with their illness. This realization is a result of strong influence of Buddhist doctrines on the participants' perspectives and their ability to let go. Specific doctrines that lead to this viewpoint include The Four Noble Truths which are: (i) all living things experience suffering; (ii) there is a cause of suffering, the cause of suffering is personal desire; (iii) there can be an end of suffering or overcoming personal desire; and (iv) one can take actions to end suffering called the Noble Eightfold Path.
Living life with contentment
Understanding and accepting that nothing is permanent guided the participants' way of living and helped them to maintain calm and harmony in living. The participants believed and accepted that ‘peace and harmony’ rather than material obsession and possession was the most important element of life. Living their lives with contentment included: living with equanimity and self-sufficiency, living with care, living with loving-kindness and compassion, and presenting a sense of gratitude.
In living with equanimity and self-sufficiency, participants lived for the moment, lived a simple lifestyle and learned to detach themselves from the sense of self. They were practising letting go or detachment rather than forming attachment. They then experienced the feeling of freedom and gained peace. Two participants reported:
Don't (make yourself) attached or be overly hopeful, (but) let go (and) do the best for today.
The real happiness is being satisfied with what we have, and realizing the transitions of all things. Whatever happens, good or bad, does not affect me. I accept them all. Whatever happens, I can face them all.
Furthermore, the participants discovered that happiness was easy experience if they lived an unassuming, self-sufficient and cautious life such as doing exercise, holding lawful employment, making merit (a Buddhist notion—merit accumulates as a result of good deeds, acts or thoughts, and carries over to subsequent incarnations), avoiding gambling and risky behaviours. As one participant reported:
Giving up gambling, consuming fresh and newly cooked dishes … We don't need to eat expensive food. At our place we have our own vegetables and fish (or other kind of home-grown vegetables and meat) … eat whatever we have (at home/or in the neighbourhood). This enhances our health status. … Also, we do not engage in unlawful activities/employment; we make merit now and then. All these acts direct us to the sufficiency economy which was the philosophy of His Majesty the King. Happiness will come and when we are happy we feel good.
In living with care, participants were influenced by understanding that life is fragile, and nothing is permanent except death. Consequently, the participants did not want to be a burden for anyone because they believed that ‘one should rely on oneself’. Thus, they lived their lives carefully and made cautious plans for when they were approaching this last state of life. The participants did their best to ensure optimal health. This led them to live a peaceful life. The cautious lifestyles were demonstrated in various ways including establishment of an end-of-life plan. As two participants said:
When my condition deteriorates, I will have my siblings and wife care for me. I have partially prepared, and I have got some savings. I have no worries.
I told my children, ‘mum is in this state (infected with HIV/AIDS); mum won't be with you forever. One day mum will leave you (pass away), so you will have to stay strong and survive.’ My only wish is to provide enough education to my children so when I am no longer around they can stand on their own legs, they won't have to depend on others. They can work and earn money.
Living with care includes being reasonable with living and having a spouse. Some participants did not plan to re-marry or to have new partner after their spouses passed away because of HIV/AIDS. They tried to be independent. This might reflect being conscious about ways of living. This act was to avoid creating risk as the participant might pass HIV/AIDS to the new partner. Also, having a new partner could create additional burden. For example, a new partner might wish to have children and this would lead to a risky circumstance because the newborn might be infected with HIV.
Living with loving-kindness and compassion involved participants helping others, making both donor and recipient feel happy and fulfilled. A number of participants committed to helping others. This way of living is the origin of the feeling of fulfilment in life that enhances happiness. One participant who became a volunteer at the hospital said:
I am glad to be able to help. I faced sorrow before so I don't want others to experience the same. When I am able to help and to make others able to smile and sleep I feel happy and fulfilled. It is a feeling that is hard to express into words. As you can see, I have never required hospitalization; I have never been allergic to the drugs. I believe that these happen because of the happiness I have acquired from being able to help others.
Presenting the sense of gratitude involved the idea that having HIV made them recognize the love from their loved ones who were always there to care for them and to give them support. This helped them to get over the life crisis.
When I was ill, my wife, my older brother and my older sister took turns to remain by my side, to bath me, to clean me up, to feed me until I got better and survived the ordeal. Therefore, I thought, I will be good; I would like to return the gratitude to them. I would like to make my parents, my brother and my sister happy. They were the ones who cared for me. I have survived because of them. My parents, my brother, my sister, my wife and my children are very valuable to me. They have given me constant support. I feel happy when I am with them and my inner strength increases each day.
The participants who were teenagers or young adults realized that they had not returned gratitude to their parents. Therefore, they wished to live longer to have a chance to look after their parents. Returning gratitude to parents by children does not mean that children have to give the parents money or valuable items, but to grow up to be a good person and able to look after themselves as well as to make the parents proud and free of worries. This reflects the custom of Thais' sense of gratitude which should be preserved because it produces inner happiness both to the performer and recipient.
Summary of Key Findings
The participants revealed a process by which they achieved peace and harmony by understanding and accepting that nothing is permanent and living life with contentment, including living with equanimity and self-sufficiency, care, loving-kindness and compassion, and presenting the sense of gratitude.
The findings illuminate the way participants crossed from the world of suffering to a new world of happiness. Although HIV/AIDS still remains in their bodies, it is viewed as a shadow which cannot eradicate them once they achieve a peaceful life. Most participants valued the calm mind that made them feel that they were in harmony with their situation. From their experience of living with HIV/AIDS, they realized that the people who have a calm mind live longer than those who do not. Then, they tried to train their mind to be calm by understanding and accepting the truth of impermanence.
In this study, Buddhist teaching played an essential role in helping participants to understand and accept that nothing is permanent. The Lord Buddha teaches that life has mind and matter and nothing more. All must depart and component things are impermanent. Everyone who is living will die sooner or later. As a consequence, an understanding of such impermanence can free human beings from getting caught in the suffering of craving, attachment, and despair.[14, 15] This realization had a strong influence on the participants' life perspectives which led them to feel calm. Some participants employed Buddhist philosophy to accept the situation by letting go of the feelings of suffering. Consequently, they accepted HIV/AIDS as part of life which helped them to feel free from the shadow of HIV/AIDS, live life normally[27, 28] and gain a sense of peacefulness. This finding is consistent with previous international studies. For example, Kruse et al. claimed that the serene person is the person who has the ability to cope with life by accepting situations that he/she knows he/she cannot change. Hall reported that feelings of anxiety about living with HIV/AIDS and imminent death were ameliorated by realizing that no one could escape death. The practice of acceptance in the face of distress is promoted in the Thai context.[28, 31-33] In addition, Buddhists believe that the mind can be trained. Thus, Buddhism focuses on teaching people to develop their minds. ‘The Four Noble Truths’, which is the heart of the Buddha's doctrine, focuses on the truth of suffering, the truth of the cause of suffering, the truth of the cessation of suffering and the Eightfold Path. Thus, the heart of Buddhist spirituality is ‘the cultivation of certain dispositions that integrate this awareness of the transient nature of all things into one's life’ (p. 82). The Lord Buddha introduced the Noble Truths to humans to help them to end suffering.
After the participants understood the truth of suffering, the truth of the cause of suffering and understood the impermanence, they then understood and accepted that ‘peace and harmony’ rather than material obsession and possession, are the most important elements in life. They learned to live with contentment by following the truth of the cessation of suffering and the Eightfold Path that is guided by Buddhist teaching. Harmony arises when the participants live their life with contentment, which included living with equanimity and self-sufficiency, living with care, living with loving-kindness and compassion, and presenting the sense of gratitude.
Equanimity is the aspect of true love. It is love without attachment and discrimination, but letting go of feelings and possessions. The person sees everyone as equal. The participants discovered that happiness was not difficult to experience if they lived a simple and self-sufficient way of life. This way of living is congruent with the philosophy bestowed by His Majesty, the King of Thailand, King Bhumibol Adulyadej, in which His Majesty the King encouraged Thai people to embrace ‘economic sufficiency’. ‘Economic sufficiency’ is a philosophy that stresses the middle path. Harmony is also achieved when the participants live with loving-kindness and compassion.[33, 35, 36] Weaver et al. (p. 129), stated that ‘central to the Buddhist approach to health and healing is its emphasis on spiritual strength and sense of purpose in life based on compassionate action for others’. It should be highlighted that most aspects of harmony in life are amplified when participants make merit. In the Thai context, harmony also arises when the participants obtain the sense of gratitude.[38, 39]
Gratitude is a deep sense of obligation and the need for affiliation and security. Portraying a sense of gratitude helps people living with HIV/AIDS to overcome their life crisis and have a will to live. Dhammananda stated that religion is significant for human beings because it enhances contentment and advises a person to look beyond the demands of themselves. Following religious teaching helps them to lead a good life and gain peace and happiness here and now.
The limitation of this study is that the study results are not to be generalized. The findings are unique to Thai Buddhists living with HIV/AIDS. However, some concepts that enhanced the participants' ability to pass through their life crisis and gain peace and harmony should be able to be utilized in the general population in particular by those with chronic illnesses or at the end of life. Health-care professionals can utilize the research findings as a basis for providing guidance to patients with HIV/AIDS or other chronic illnesses; in particular, the understanding that nothing is permanent and ways of living life with contentment in order to help them gain peace in their life. Furthermore, this study has pointed out that the similar studies,[13, 41, 42] but of different religions, potentially yield beneficial results which can be applied to support patients who are not Buddhists.
All people have the ability to reach the feeling of peace and harmony even if they are poor in terms of material possessions. However, some people cannot achieve it. These research findings describe the process of Achieving Peace and Harmony in Life of Thai Buddhists living with HIV/AIDS in Southern Thailand. Hence, the research findings could be valuable to health professionals in Thailand and internationally to assist patients in achieving harmony.
We thank the National Research Council of Thailand which provided financial support for this research. We appreciatively acknowledge the willingness of participants to share their experiences. We also thank the nurses, counselors and health volunteers for their helpful assistance in making contact with the participants. We also appreciate the assistance of Dr Piyaporn Boonphadh, Ph.D., RN. and Mr David A. Bruner, Prince of Songkla University, Thailand M.A., LL.B. in revising this manuscript.
Quantar Balthip contributed in the study in its conception, design, data collection, data analysis, drafting of manuscript; Usanee Petchruschatachart and Siriwan Piriyakoontorn in data collection and data analysis; and Julie Boddy in the critical revisions for important intellectual content, supervision and drafting of manuscript.
The authors declare no conflict of interest.