Acquiring of knowledge about sexual health by blind people: an action research

Objective: to evaluate knowledge about sexual health, with blind people, before and after educational intervention. Method: action research conducted with 58 blind people enrolled in a philanthropic educational institution. A form with sociodemographic and knowledge variables about Sexually Transmitted Infections was used. The Chi-square and Fisher tests were performed. Results: men presented higher frequency of alcoholism (p <0.001) and illicit drugs (p = 0.006). It was found that they used a male condom more frequently than women using a female condom (p = 0.003), although they had more knowledge about the prevention of Sexually Transmitted Infections (p = 0.006). Among these infections, Trichomonas vaginalis (52.4%) was more frequent. Knowledge gaps on risk factors and safe sex were identified. After the intervention, an increase in the knowledge about sexual health was detected. Conclusion: the educational intervention, in the light of problematizing pedagogy, (re) constructed the knowledge on sexual health, empowering the participants regarding the prevention of Sexually Transmitted Infections. Therefore, it is necessary that nurses carry out educational interventions with this clientele, aiming to soften deficits of knowledge about the thematic in screen.


Introduction
In Brazil, Sexually Transmitted Infections (STIs) are considered a serious public health problem, despite the existence of a national policy for the prevention and treatment of STI / Acquired Immunodeficiency Syndrome (AIDS). It is stated that in many health centers across the country there is a shortage of physicians and nurses adequately trained to care for patients with these infections (1) .
In addition to the exceptions and unpreparedness of some professionals, it is considered that the estimated incidence of human papillomavirus (HPV) infection is of the order of 685,400 new cases annually (2)(3) . There is a need to intensify campaigns for clarification and prevention in relation to Chlamydia trachomatis and Neisseria gonorrhoeae and to the possible infertility due to these treatable infections, which mainly affect the young population of lower income (4) . Therefore, if the incidence or prevalence of STIs is high in a country or region, groups that are vulnerable to STIs, in the biopsychosocial and socio-cultural aspects, are at greater risk of sexual transmission by HIV (5) .
It is worth noting that, despite the prevention and treatment of STIs being practices inserted in family planning, the access of users with this type of infection is marked by minimal demand (6) . In this context, the segment of people with visual impairment is among the groups most vulnerable to health risks (7) , since visual loss entails disadvantages and restrictions on participation and performance in daily activities, impairing independence, the autonomy and the quality of life of people with this aggravation (8) .
These people usually narrate feelings of rejection or overprotection in the family, difficulties in acquiring orthoses and prostheses for autonomy, little investment in study and professional qualification, as well as confronting physical and attitudinal barriers in health services, as well as obstacles to the sexuality and motherhood (9) . It can be observed that stigmas about the sexuality of the population of people with disabilities are still present in the 21st century, with the belief that they cannot have children or even practice the sexual act (7,(9)(10) .
In the case of women with disabilities, the primary care services do not recognize the sexual and reproductive rights and the double vulnerability that affects them, a fact that causes the persistence of the profile of fragility in the health care of these people due to the disarticulation and discontinuity of actions in the public and private spheres and the low level of coverage of care (9) .
In the case of blind people, the sum of the myths and taboos about sexuality, their inherent vulnerability and the difficulties of access to health services, has repercussions on sexual and reproductive health, in view of exposure to the risk of contracting STIs. In this sense, it is indicated the possibility of occurrence of these infections by the disinformation about the prevention, since the health policies and the preventive campaigns are directed to the visionary public and are not adapted for this social segment, which increases its vulnerability (7,(9)(10)(11) .
In this context, it is up to the Nursing professional to plan and execute health education actions, aiming to (re) build their knowledge about sexual and reproductive health and to prevent / reduce STI cases (6) . In this way, health education makes it possible to meet the information needs of users of the Unified Health System, considering that this action is based on the development of activities that enable the empowerment of people for self-care and health promotion (12) .
In view of the above, this study sought answers to the question: how blind people care for sexual health? It is considered imperative to carry out this research that can positively contribute to the Nursing intervention, through the use of health education, to promote the This research has the potential to contribute to the actions of Nursing in the field of sexual health education for people with disabilities, since the report of the characterization of the vulnerability situation of these people enables managers and health professionals to plan strategies and actions of prevention in line with the social and health reality of these individuals. In addition, it is justified that the issue of people with disabilities can be found in the National Agenda for Priorities in Health Research.
In this perspective, the objective was to evaluate the knowledge about sexual health, together with blind people, before and after educational intervention. and were assured of secrecy, privacy and the right to decline, at any time investigation, without any kind of burden due to the withdrawal.

Results
As a result of sociodemographic characteristics,  As shown in Table 3, after the intervention, the increase in knowledge about signs and symptoms of STI was detected, and knowledge was verified on all variables above the quartile 75.
When considering the before and after the educational intervention, participants' knowledge was improved, with emphasis on infertility and chronic pelvic pain, which reached 93% and 86%, respectively, according to data from Table 4.
After the educational intervention, it was also verified that the STIs with the highest percentages of knowledge were: AIDS, syphilis and gonorrhea (100%), according to data shown in Table 5.

Discussion
The sociodemographic characteristics of the participants in this study differ from those found in another study carried out in the city of Uberaba, Minas Gerais, Brazil, with 33 people with visual impairment, in which the highest prevalence was found among women and most retirees, but they are similar regarding the educational level (16) .
The association found in this study between sex and variables related to health and STI prevention corroborates another investigation with blind people in which an association between STI-related sexual practice and sex was identified. However, this same research did not identify an association between sex and knowledge about STI prevention and transmission, a fact that can be explained by the small sample size (n = 36) (17) .
The age range of the majority of the participants in this study classifies them as productive working age,  (18)(19) , so that personal / spiritual well-being and self-esteem improve the quality of life (20) . the need for sex education as a path to social inclusion (7) .
In addition, unseen women are perceived as inhabiting a body that dissociates from the current social prototype, which makes them discredited for the role of caregivers, wives and mothers (9) . In this sense, in a study carried out in Nepal, with pregnant and disabled women, the participants reported embarrassment in exposing their own body, a barrier to the demand for care. In turn, health professionals felt unprepared to meet the health needs of pregnant women with disabilities (22) .
Regarding the sexual and reproductive health of blind people, it was observed in this study that 36.2% of the participants reported involvement due to Sexually with visual impairment (11) and aimed at health education in primary care, school or other environment, with a view to sensitizing visually impaired women for the use of the female condom (23) .
According to the data of this investigation, the In addition, when it comes to the vulnerability of the participants in this study, the consumption of alcohol or illicit drugs can lead to risky sexual behaviors, such as low condom use. This relationship was strengthened by a study report in which, in the female sex, associations were identified for seropositivity and consumption of drugs, alcoholic beverages and other drugs; being married or in stable union. In the male sex, there were associations of seropositivity with consumption of other drugs and homosexual/ bisexual orientation (25) .
These situations predispose to exposure to STIs Although the women in this study claimed to have unprotected sex, they all knew the ways of preventing STIs, but considerable numbers of men were unaware of them. It is understood that misinformation in the context of sexual health entails limitations for people, since they require specific components for access to information (11) , in addition to expanding the possibilities of contracting  (29) .
From this perspective, it was evidenced that the educational practice, mediated by the problematizing pedagogy, presented potential of modification of the knowledge of blind people in a way that these sought reflections from stimuli to solve problems (13)(14)(15) . This characteristic is limited to the educational intervention used as innovative health technology, which used a consolidated educational trend for a blind public to reflect on a theme considered taboo in this social segment. Therefore, the study is relevant to the scientific knowledge divulged, representing progress in the subject that, in recent years, was object of another study, in which it was tried to make accessible the knowledge about STI for blind people through the validation of educational text (11) .
The limitations of this study are related to the use of variables with self-reported responses, which allows memory bias, the impossibility of performing a larger quantitative of educational meetings, due to the mobility difficulties experienced by the participants, as well as having analyzed only the acquisition of knowledge , to the detriment of behavior change.
It is considered that this study has the potential to contribute to the nursing actions in the field of sexual health education for people with disabilities, since the characterization of the vulnerability situation of these people enables health managers and professionals to plan strategies and actions of prevention in line with the social and health reality of these individuals.

Conclusion
The results indicate that, before the educational action, the participants' knowledge about STIs was aiming at the demystification of prejudices that reinforce the vulnerability of these people , compromising the experience of sexuality and the preservation of sexual and reproductive health. It is necessary that nurses devote greater attention to this population group, which has insufficient basis for the care with sexual health, as it faces social barriers that make difficult the search for knowledge regarding health promotion.
In this perspective, it is suggested that other studies approach the same subject, aiming to evaluate the attitudes and practices of people with disabilities after health education, in order to verify the behavioral modification regarding the participant's sexual and reproductive health.