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Print version ISSN 0080-6234
Rev. esc. enferm. USP vol.46 no.3 São Paulo June 2012
Ana Izabel Oliveira NicolauI; Samila Gomes RibeiroII; Paula Renata Amorim LessaIII; Alana Santos MonteIV; Elizian Braga Rodrigues BernardoV; Ana Karina Bezerra PinheiroVI
IPh.D. student in Nursing, Universidade Federal do Ceará. Assistant
Professor, Undergraduate Nursing Program, Universidade Federal do Piauí.
Fortaleza, CE, Brazil, E-mail: email@example.com
IIMaster's student in Nursing, Universidade Federal do Ceará. Fortaleza, CE, Brazil, E-mail: firstname.lastname@example.org
IIIMaster's student in Nursing, Universidade Federal do Ceará. Fortaleza, CE, Brazil, E-mail: email@example.com
IVUndergraduate Nursing student, Universidade Federal do Ceará. Grantee, Tutorial Education Program / MEC-Sesu. Fortaleza, CE, Brazil, E-mail: firstname.lastname@example.org
VUndergraduate Nursing student, Universidade Federal do Ceará. Grantee, Tutorial Education Program / MEC-Sesu. Fortaleza, CE, Brazil, E-mail: email@example.com
VIPh.D. in Nursing. Adjunct Professor III and Deputy Coordinator, Graduate Nursing Program, Universidade Federal do Ceará. Fortaleza, CE, Brazil, E-mail: firstname.lastname@example.org
The objective of this study was to evaluate the knowledge, attitude and practices of women prisoners regarding the use of female and male condoms as a means of prevention against STD/HIV. This quantitative and evaluative Knowledge, Attitude and Practice (KAP) study included 155 female prisoners. Data collection was performed between January and March 2010 at the State of Ceará Women's Penitentiary. Although the women had heard of and/or knew about the purposes of the use of condoms, only 35 (22.6%) had appropriate knowledge regarding male condoms, and 11 (7.1%) in regards to the use of female condoms. Their attitudes were less favorable regarding oral sex. Appropriate practice was not significantly representative, particularly regarding the female condom. Homo/bisexuality, gender issues, lack of knowledge, and the difficult access to condoms are obstacles that must be considered in the promotio
Descriptors: Women; Prisoners; Condoms; Communicable disease prevention; Health knowledge, attitudes, practice; Nursing
As a product of social construction, violence has increased criminality in small and large centers around the world. Historically, the male gender has been more associated with crime and represents a majority of prisoners in Brazil, so that women's share in the prison scenario corresponds to 5.31%(1). Despite their smaller share, women are more vulnerable to the physical and psychological problems inherent in the prison context(2).
The social representation of female criminals tends to be that of a young woman, of low socioeconomic and educational level, unemployed, prostitute, single or divorced, from urban centers and with deficient access to health services, who were mostly arrested for drugs traffic(2).
In combination with this unfavorable profile, the prison environment offers greater exposure to physical and psychological risks and infectious disease transmission, so that prison populations, in any part of the world, tend to need further health care(3).
Few studies exist, however, about women's health problems and prevention forms in Brazilian prisons, more specifically of Sexually Transmitted Diseases (STD)/HIV, which are more prevalent problems in the occurrence and adoption of risk behaviors among prisoners than in the general population(4).
The main risk factors that further the dissemination of these illnesses among female prisoners include: promiscuity and sexual abuse, bi/homosexual activities, cell overcrowding, drugs use, tattoos and body piercing, low usage level of condoms in sexual intercourse, prostitution and history of STD. In Brazil, sexual intercourse remains the main HIV transmission route among prisoners(5-6).
The combination of all mentioned aspects with female biological characteristics, gender inequality, stigma and discrimination enhance female prisoners' vulnerability to STD/HIV. Moreover, the majority comes from socially marginalized groups, with greater probabilities of having suffered gender violence or having a history of unprotected sexual behavior(7).
In Brazil, unprotected sexual activity is considered the most significant risk factor for STD/HIV transmission in prisons, which makes condom use in sexual relations fundamental for prevention in the prison system. The relevance of STD/HIV prevention in prisons is emphasized in the National Prison System Health Plan (PNSSP), which establishes STD/HIV/aids diagnosis, counseling and treatment actions, condom distribution to prisoners and workers, elaboration of education and instruction material, specific drugs supplies, as well as STD diagnosis and treatment actions according to the syndromic approach(8).
Despite the establishment of so many actions for implementation by the health teams in the PNSSP, including the nursing team, the non-adoption of condoms as a prevention measure remains a constant among female prisoners, whether on the occasion of intimate visits or during illegal relations inside the cells(7-9).
Therefore, further attention to the health promotion of female prisoners is fundamental, not only because of the risks present in the prison context, but also due to the lack of preventive actions in the prison health system. This panorama and reflections on nurses' role to disseminate their activities involving stigmatized populations, in this case as members of the PNSSP, aroused our interest in developing this study.
In view of the influence of knowledge and the perceived importance of adopting preventive measures in health (attitude) on the transformation and development of personal skills to conquer health promotion, the relevance of answering the following question is understood: what is the knowledge, attitude and practice of female prisoners concerning the use of male and female condoms as an STD/HIV prevention measure?
Investigating the three components mentioned will indicate the diagnostic conjuncture about what the prisoners know, think and practice in terms of condom use. This assessment provides support for the development of future policies and educative strategies to facilitate the approach of STD/HIV in a distinguished way and in line with the singularities of the group under analysis.
The aim is to assess the knowledge, attitude and practice of female prisoners towards the use of male and female condoms as an STD/HIV prevention measure.
This is a cross-sectional Knowledge, Attitude and Practice (KAP) assessment study with a quantitative approach. KAP surveys are part of a category of assessment research, called formative assessment, i.e. besides obtaining data on a specific population, these studies identify possible routes for a more effective future intervention. It can be adapted to different contexts with a view to the strategic planning of health promotion interventions(10).
The research context was the female penitentiary in the State of Ceará. This institution is located in Aquiraz CE, can received 300 prisoners and is being restructured with a view to compliance with the PNSSP. It is already offering a health team (nurse, nursing technicians, general clinician, pediatrician, gynecologist, dentist, dentistry aid, social worker and psychologist) and an outpatient clinic.
The study population considered women imprisoned at the institution during data collection, excluding cases of cognitive limitations that would impede information provision for data collection purposes. Applying the calculation for finite populations, the sample resulted in 155 women, based on a population size of 258 prisoners, with a 95% confidence interval, 0.05 maximum permitted error and 50% prevalence level.
Data collection took place between January and March 2010. Initially, the researchers and prison agents held a campaign to disseminate the study across the institution, which took about one week. Thus, on the information collection days, the prison guards escorted the women who had previously manifested their interest from the cells and work places inside the institution to the school in groups of five. Individual interviews were held in the classrooms located inside the penitentiary.
The instrument used first addressed socio-demographic characteristics. Next, the KAP survey was applied (Attachment A), concerning male and female condoms as an STD/HIV prevention method. This instrument was adapted from a KAP model on colon cancer prevention(11). In this study, the knowledge, attitude and practice concerning male and female condoms as STD/HIV prevention methods were assessed as follows:
- Adequate: having heard about the male and female condom, knowing that they serve to prevent STD/HIV in general and unwanted pregnancy and being able to mention at least three forms of care needed for the correct use of each method;
- Inadequate: never having heard about the male or female condom or having heard, but not knowing that they serve to prevent STD/HIV; or when the respondent could not mention at least three forms of care needed for the correct use of the methods.
- Adequate: when the women mention that using the male or female condom is always necessary in all sexual practices;
- Inadequate: when the women indicate that using the male or female condom is unnecessary, hardly necessary or not having an opinion on its need.
- Adequate: when the women indicate that they always use the male or female condom from the beginning until the end of the sexual practices performed; no unwanted pregnancies; no diagnosis of STD since their institutionalization.
- Inadequate: when the women indicate that they do not always or never use the male or female condom in sexual practices, or when they indicate that they do not always use a condom from the beginning until the end of sexual practices; unwanted pregnancy or diagnosis of STD since their institutionalization.
Data were compiled using Statistical Package for the Social Sciences (SPSS) version 17.0 and then organized in the form of tables with absolute and relative frequencies. Then, knowledge and attitude variables were compared with male or female condom usage practice for STD/HIV prevention. Pearson's Chi-square test was used for statistical associations.
The prisoners were verbally invited to participate in the research and received clarifications about the aims and procedures involved. Acceptance was formalized through the signing of an informed consent term, using the prisoner's signature or fingerprint. Ethical aspects of research involving human beings were complied with, in accordance with National Health Council Resolution No. 196, issued in 1996(12). The project received approval from the Research Ethics Committee at UFC, under protocol No. 229/09.
The socio-demographic characteristics pointed towards a young population, with a mean age of 29.4 years, mostly single 70 (45.2%), and who are being tried for drugs traffic 82 (52.8%), theft 31 (20%) and robbery 26 (16.7%).
Data on the educational level revealed that more than half of the participants (88, i.e. 56.8%) did not finish Primary Education. Moreover, the maximum education level for 115 (74.2%) was completed primary education.
The analysis of their previous occupation before they were imprisoned showed a population that especially had non-remunerated or low-paid jobs (domestic servant, saleswoman and cleaning aid). About 13% were unemployed and 87 (56.1%) mentioned a monthly income of one minimum wage at most.
The assessment of the 155 participants' knowledge about male condom (MC) use evidenced that 35 (22.6%) possessed adequate knowledge, although the entire group had already heard about this method, which demonstrates that the knowledge gained was superficial. The assessment about female condom (FC) use revealed more unsatisfactory results, as only 11 women (7.1%) had adequate knowledge, although 138 (89%) had already heard about the condom. The superficial knowledge problem arouses reflections about how the orientations are reaching these women and who is transmitting them.
Thus, the analysis of information sources indicated health professionals, school and television/radio as the main orientation means, which demonstrates the need to improve the quality of these professionals' care and to put in practice new health education strategies, whether at health services, school or in the media.
When asked about the reasons for using the male condom, 138 participants (84.5%) considered STD/HIV and unwanted pregnancy prevention as the main goal. It is highlighted that, in total, 153 women (98.7%) mentioned the protective function against STD/HIV, and that only 2 (1.3%) did not know the purpose of the male condom. In the analysis of the reasons for using the female condom, on the other hand, 109 (70.4%) affirmed that it serves to prevent STD/HIV and unwanted pregnancy, but the number of women who could not mention any function of the female condom was about ten times higher than that of women unfamiliar with the functions of the male condom.
The final phase of the knowledge assessment involved the description of at least three care forms needed for the adequate use of the methods involved. Sixty-eight (43.9%) of the women could not mention any form of care with male condom use, and only 35 (22.6%) demonstrated sufficient knowledge to describe three adequate care forms.
Greater difficulties appeared in the description of female condom use, so that only 12 (7.1%) were able to indicate three care forms, i.e. 14.9% less than those who managed to describe male condom care. Almost all women, i.e. 130 (83.9%) were unable to describe any care form, which means 40% more women were unfamiliar with care for female condom use than with male condom use. The analysis indicated that 87 prisoners (56.1%) managed to mention some correct care form for male condom use, against only 25 (16.1%) for the female variant.
The description of the care mentioned for using male condoms is displayed in Table 1.
A range of care forms was described, from measures to be taken before opening the package until after usage.
Among inadequate care, hand washing was the most frequent, and was mentioned 7 times (38.9%). The importance of hand washing as a hygiene and protection habit is well known, but it was classified as inadequate, because it does not represent a necessary measure to use the method.
Care described for using the female condom is displayed in Table 2.
Reports on the placement phases showed the most prevalent care forms. The prisoners mentioned the care needed to open the package, check the integrity of the package and female condom, correct positioning in the body and how to proceed after use with lower frequency levels. Only three care forms were considered inadequate, as two women mentioned that, when removing the female condom, it should not be twisted to contain the seminal fluid and facilitate its removal.
The assessment of attitudes towards the need to use the male condom always and in all types of sexual practices (oral, vaginal, anal) resulted in 95 participants (61.3%) with adequate attitudes.
The most adequate attitude was perceived during the vaginal coitus, as only 5 (3.2%) considered it hardly necessary, 2 (1.3%) unnecessary and 11 (7.1%) did not opine. The attitude showed to be less positive in answers concerning opinions about use during anal and oral sex. This, in turn, showed the largest number, 13 (8.4%), of assertions about the unnecessary use of the male condom, while 29 (18.7%) had no opinion.
About the attitude towards the use of the female condom, again, vulnerability perception levels were lower with regard to oral sex. Less than half, 73 (47.1%) found it necessary to use the female condom always in oral and vaginal practices. About 10% found it unnecessary or had no opinion about condom use during oral sex when compared with vaginal intercourse.
The analysis of condom use practices showed less favorable results than for the knowledge and attitude components. This assertion was based on the fact that only 29 women (18.7%) revealed adequate male condom practices, i.e. they use it always, in all sexual relations, from the start until the end. The female condom usage situation was even more negative, as only two participants (1.3%) used it adequately.
Concerning usage consistency, 31 women (20%) used the male condom always in all sexual practices, and two (1.3%) consistently used the female condom. The remaining women either did not use it always in all practices or never used it, particularly the female condom.
To investigate how STD/HIV prevention actions are being developed at the research institution, the participants were asked about how they received condom, at what interval and orientations about usage.
The collected data showed that 63 women (40.6%, less than half) received condom use orientations inside the prison. Among those who received some orientation, the main sources were: educative activities 23 (36.5%), nurse 19 (30.1%) and physician 8 (12.7%). These data are a source of concern, as only 19 (12.2%) out of 155 women received nursing and 8 (5.1%) medical orientations, which demonstrates the urgent need to strengthen health education in the prison context.
Information about condom reception showed that 98 (63.2%) do not get them at the institution. Among those who do, 15 (26.3%) affirmed that they receive them exclusively on celebration dates, 14 (24.5%) every two weeks, in this case women receiving intimate visits, 9 (15.7%) rarely and 5 (8.7%) only when condoms are left from other prisoners or when they ask for them. None of the participants mentioned receiving female condoms at the institution.
Among the main referred reasons for not using the male condom, homosexuality stands out with 36 (29%). Next are the two main bottlenecks for the consistent use of the prevention device, which is trust in the sexual partner, 34 (27.4%) and the fact that the man does not agree to use it, 31 (25%).
As for the difficulties mentioned to use the female condom, the main reason is related to knowledge, as 52 (34%) indicated they did not know this device, affirming the weakness of sexual health promotion actions. Other unfavorable reasons were never having taken any interest, with 14 (9.1%) and access difficulties with 11 (19.2%). Lack of knowledge, interest and perceived vulnerability aggravate access difficulties even further.
Associations among (KAP) components
The analysis of Table 3 reveals that, despite the non-significant association (p>0.05) among the KAP components, women with adequate knowledge showed higher adequate attitude percentages for both condom types. The adequacy of knowledge and attitudes was not associated with adequate practices though, neither for the male nor for the female variant.
The condom is one of the most disseminated and known contraceptive and STD prevention methods, but correct use and adequate knowledge on how to use it are not as frequent as the fact of "having heard about it"(13). The weak knowledge about male and female condoms among the study participants reflects the ineffectiveness of how orientations are being provided.
The orientations offered at health services, as well as in other environments, should go beyond the superficial, which requires professional preparation and skills to truly provide health education. Health professionals' competency should include orientation, information and communication skills(14).
One important health care aspect that is especially relevant for imprisoned women refers to the improvement of their knowledge and understanding about health issues. The offering of health education programs is imperative. Disease treatment and condom distribution should be accompanied by prevention, sensitization and education programs for the prisoners(9). The Ministry of Health recommends that Brazilian penitentiaries maintain permanent information services for prisoners and relatives with a view to STD/HIV prevention, offering condoms and support needed for safe sexual practices(8).
While difficulties are faced to put the guidelines in practice, reality shows that women have less access to health services in the penitentiary system in comparison with imprisoned men. Health education material, besides information and services, including those focused on HIV and drugs addiction, are often more limited at female than at male prison units(7).
Also concerning the knowledge investigation, the distribution of findings about the reasons for using the condoms is similar to a population-based study of 3,542 people, male and female, living in Pelotas. The authors concluded that more than 75% of the women were familiar with the condom as a protection factor against illnesses and/or aids. Despite knowing its main function, when they use it, they indicate contraception as a justification(15). Condoms can be effective to prevent both pregnancy and STD/HIV. Although they do not guarantee "totally safe sexual relations", condoms substantially reduce individual STD/HIV risks, provided that they are used correctly in all types of sexual intercourse(16).
Mastering care for condom use is fundamental to promote safe and effective practice. Couples need to be oriented on the phases that guarantee the best possible use. Therefore, health professionals need to use educative technologies to reach positive results for the development of personal skills for the management and handling of this contraceptive and preventive method.
The female prevention artifact involves women's intimate contact with their genital organ, a condition that reduces interest in the method. Knowing this, professionals should adopt strategies to arouse curiosity and encourage them. Mastering the placement steps is essential, as the method enhances autonomy, increases self-esteem, furthers negotiation ability and expands their decision-making skills(17).
Condom use is a complex behavior that involves values and opinions as well as affective and sexual aspects. Positive attitudes enhance the population's interest in the search to adopt healthy practices. Although knowledge and attitude are not sufficient to transform and maintain behaviors, the importance of these elements as parts of the empowerment process in health is well known.
The deeper analysis of attitudes towards condom use always and in all sexual practices showed less perceived vulnerability during oral practice. The population needs to be informed that STD/HIV can be transmitted or acquired during any sexual act, but some acts are more risky than others.
Vaginal sex is risky for both partners when no condom is used, due to the fluid exchange. Anal sex entails a great risk of STD/HIV transmission, as the anus and rectum are covered with mucous tissue rich in blood vessels, which can be injured during the penetration. The risk of HIV infection is five times higher in unprotected receptive anal sex than in unprotected receptive vaginal sex. Oral sex is considered of lesser risk(16).
Longitudinal actions to monitor changes in opinions on the adoption of preventive measures are not a reality at health services. Educative activities to increase knowledge are widely disseminated, but take place punctually, without discerning the need for a continuous process of evaluation and re-adaptation of strategies to achieve attitude transformations and true empowerment. The challenge is to permit the fact that health education represents a process that combines the articulation between knowledge and values, but that extends to their effect in attitudes and health practices.
To put in practice the preventive methods involved, the need for correct and consistent use needs to be emphasized, with a view to their effectiveness to reduce STD/HIV transmission risks. Their availability should be incorporated into health service routines, accompanied by adequate orientations. These actions extend to the prison environment, which demands not only available prevention inputs from the team, but also preparation to orient on correct and safe use. It is highlighted that one of the goals of the PNSSP is to offer condoms to 100% of prisoners and 60% of prison guards(8).
The data obtained in the analysis of the practical component showed that the way actions are being put in practice to reach the established goal is not sufficient to guarantee practice. One possible route could be the World Health Organization's suggestion, according to which condoms need to be easily accessible in different place in prisons, so that the prisoners do not have to ask and can get them without guards or other prisoners seeing them(9).
The difficulties found concerning adequate condom practice in this study are similar to other studies that also involved prison populations. In Goiânia, in a sample of 82 prisoners, 54% indicated occasional and 20.7% rare use(13). A study in São Paulo, involving 299 female prisoners, inferred that the non-use of condoms in the previous year during sexual intercourse with men was observed in 95 of them (60%), while the others mentioned irregular use. None of them reported regular use or use during sex with women(6).
As for female condom use, no studies have been developed about its acceptability among female prisoners. According to an Ibope survey among 1,298 sexually active women, 2.5% said they used the female condom(18). In view of these results, the lower adherence levels among the women in this study are evidenced, as only two of them (1.3%) used the female condom adequately.
Among the alleged reasons for not using condoms, the occurrence of homosexual women stands out. The lack of risk perception makes it difficult to include the condom in sex between women. The male condom should be further valued, especially when sharing erotic accessories, while the female variant would be more applicable, as it decreases direct contact with secretions and possible ulcerations while handling these devices, and also during oral sex(19).
It should be guaranteed that the contents of educative programs for the prison population addresses issues related to discrimination concerning aids, homophobia, the stigma associated with partners of the same sex, as well as with discrimination through prostitution and drugs use(3).
Another limitation of the method for women is the dependence on use by the partner, affecting their right to a free choice when he does not accept to use it. In this context, there is an increasing need to offer the female condom as a way to expand protection possibilities and decrease gender inequalities(17). The Ibope survey results showed the predominance of no condom use in the most recent sexual intercourse in 30.2% due to trust in the partner and 22.8% because they are married or have (a) fixed partner(s)(18). Negotiation difficulties, fear of provoking trust in the partner and loss of the relationship's structure are social, personal and cultural risks many women are not willing to take(20), which can represent further obstacles for condom use than lack of knowledge.
What aggravates this situation even further is that the affective relations female prisoners experience are sometimes marked by affective dependence, conformism and hiding or even out of fear of the partners' rejection. According to them, maintaining the partner's support is still important to guarantee emotional and financial support as, sometimes, it is the only form of support they have at their disposal(21).
The results described under the association between KAP components once again appoint the fragility of condom use promotion actions and strategies in the prison institution under analysis. The fact that individuals have knowledge and positive attitudes facilitates but does not guarantee the adoption of preventive behaviors, especially without appropriate support and conditions to enhance this behavioral change and maintain practice. The irregular distribution to prisoners without intimate visits, difficulties concerning access and the sexual partner's acceptance of condom use can represent bottlenecks for consistent condom use in relations inside the prison environment, which hampers the direct influence of knowledge and attitudes.
The socio-demographic profile found pictures many young Brazilians living in situations of lost family, social and economic structure. The weakness of public policies to guarantee high-quality education, housing, leisure, food and professional qualification make it difficult for many people to achieve quality of life and ascend in society. The vulnerabilities characteristic of youth, articulated with a life that does not envisage a promising future, catalyze criminality in the country.
As for knowledge about condoms, the superficiality of this component was verified. In view of fragile information, reflection is due about the knowledge enhancement strategies the main referred sources (health professionals, school, media) provide. Actions to promote sexual and reproductive health among female prisoners should not remain restricted to gynecological consultations and condom distribution. Institutional spaces like the school, work places, the recreation area, as well as the cells, should be better used for the development of education groups, based on participatory, dialogical and processual knowledge construction.
The dialogical process should mainly involve attitude changes. In view of this premise, the evaluation study diagnosed less favorable attitudes towards female condom use and the use of male and female preventive barriers during oral sex. These findings indicate situations that should be taken into account in skills development for STD/HIV prevention in the group under analysis.
Adequate condom practice was hardly representative, especially considering the female condom, mainly due to inconsistent use, in view of the barriers found for adequate practice, strategic action planning to prevent STD/HIV in female prisons should address the gender issues that make women historically vulnerable, the occurrence of homosexual relations and their restricted knowledge on health care, perhaps due to a history of few educational opportunities.
The KAP components showed no statistical associations. In other words, adequate knowledge and attitudes were not sufficient to guarantee adequate practices. Possible explanations include difficulties to negotiate on condom use between partners, restricted access and the "illegal" circumstances in which homosexual relations take place. In view of the results, sexual health promotion strategies in prison contexts should cover the complexity of the factors involved in the condom use outcome. To strengthen the subjects' autonomy as the essence of the educative process, and to take into account knowledge and opinions, the contexts of environment, social, cultural and emotional vulnerabilities should be combined.
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