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Social representations of adolescents about HIV/AIDS transmission in sexual relations: vulnerabilities and risks

ABSTRACT

Objective

To understand social representations of adolescents about vulnerabilities and risks of contracting HIV/AIDS in sexual relations.

Method

Study of social representations, based on individual interviews with 15 adolescents and a focus group with eight adolescents from a public school in Recife, Pernambuco, Brazil. Data were collected from May to October 2016. For the processing of data, the thematic-categorial content analysis technique was used with the aid of the QSR Nvivo11 Software.

Results

The categories: risks of contracting HIV/AIDS in sexual relations; and from the risks of contracting HIV/AIDS in sexual relations to the vulnerabilities cover the themes of not using condoms, having used alcohol and/or drugs, having several partners, having difficulties in accessing health and sex education services in schools; and not having conversations with parents or family members.

Conclusion and implications for practice

it was understood that social representations circulate in the imaginary and in the school environment, interfering in the reality of adolescents. It is proposed to prioritize public policies focused on the emotional, affective and social dimensions.

Keywords:
Social Perception; Adolescent; Sexual Health; HIV; Nursing

RESUMO

Objetivo

compreender as representações sociais de adolescentes sobre vulnerabilidades e riscos para contrair o HIV/Aids nas relações sexuais.

Método

estudo de representações sociais, realizado a partir de entrevistas individuais com 15 adolescentes e grupo focal com oito adolescentes de uma escola pública do Recife, Pernambuco, Brasil. Os dados foram coletados no período de maio a outubro de 2016. Para tratamento dos dados, empregou-se a técnica de análise de conteúdo temática-categorial com o auxílio do Software QSR Nvivo11.

Resultados

as categorias: riscos de contrair HIV/Aids nas relações sexuais; e dos riscos de contrair HIV/Aids nas relações sexuais às vulnerabilidades abrigam os temas não usar preservativo, ter usado álcool e/ou drogas, ter vários parceiros, ter dificuldades de acesso aos serviços de saúde e de educação sexual nas escolas; e não ter conversas com os pais ou familiares.

Conclusão e implicações para a prática

compreendeu-se que as representações sociais circulam no imaginário e no ambiente escolar, interferindo na realidade dos adolescentes. Propõe-se priorizar políticas públicas focadas nas dimensões emocionais, afetivas e sociais.

Palavras-chave:
Percepção Social; Adolescente; Saúde Sexual; HIV; Enfermagem

RESUMEN

Objetivo

comprender las representaciones sociales de adolescentes acerca de las vulnerabilidades y riesgos de contraer el VIH/SIDA en relaciones sexuales.

Método

estudio de representaciones sociales realizado a partir de entrevistas individuales con 15 adolescentes y un grupo focal con ocho adolescentes de una escuela pública en Recife, Pernambuco, Brasil. Los datos se recolectaron entre mayo y octubre de 2016. Para el tratamiento de los datos, se utilizó la técnica de análisis de contenido temático-categórico, con la ayuda del software QSR Nvivo11.

Resultados

las categorías riesgos de contraer el VIH/SIDA en las relaciones sexuales; y de los riesgos de contraer el VIH/SIDA en las relaciones sexuales a las vulnerabilidades que cubren los temas de no usar condón, haber consumido alcohol y/o drogas, tener varios pares, tener dificultades para acceder a los servicios de salud y de educación sexual en las escuelas; y no tener conversaciones con los padres o miembros de la familia.

Conclusión e implicaciones para la práctica

se entendió que las representaciones sociales circulan en el imaginario y en el ámbito escolar, interfiriendo en la realidad de los adolescentes. Se propone priorizar políticas públicas enfocadas en las dimensiones emocionales, afectivas y sociales.

Palabras clave:
Percepción Social; Adolescente; Salud Sexual; VIH; Enfermería

INTRODUCTION

The number of new cases of the human immunodeficiency virus (HIV) continues to increase among adolescents over the years. In Brazil, in 2018 alone, 21% of all new HIV diagnoses occurred in adolescents, of which 87% were men aged 13 to 19 years, and the main route of transmission was sexual11 Brasil. Ministério da Saúde. Boletim Epidemiológico HIV e Aids-2018 [Internet]. 2018 [citado fev 01 2021]. Disponível em: http://www.aids.gov.br/pt-br/pub/2018/boletim-epidemiologico-hivaids-2018.
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In this sense, there is an urgent need to enable adolescents to recognize their chances of contracting HIV/AIDS and protect themselves from it and other sexually transmitted infections (STIs).

To deepen the understanding and contribute to this theme, this study adopted the definition of vulnerability that refers to the complexity of intersubjective relationships and the social and political contexts related to systematic situations of disrespect for rights that lead to greater exposure to damage to the health, considering the capacity for social recognition and response to people’s health issues22 Ayres JR, Castellanos MEP, Baptista TWF. Entrevista com José Ricardo Ayres. Saude Soc. 2018 jan;27(1):51-60. http://dx.doi.org/10.1590/s0104-12902018000002.
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. This definition will be discussed as counterpoint to the risks, which only consider the probability or chances that an adolescent has of contracting the virus in relation to the population of other age groups.

In this sense, it is understood that the overcoming of risks and vulnerabilities involves the guarantee of the right to a safe and healthy sexual development, through the implementation of health promotion strategies and prevention programs that seek to improve the early detection rates of cases, since the adolescent population does not recognize itself as vulnerable, even after unprotected sex, and that the beginning of sexual activity is increasingly precocious. These strategies and programs must consider not only risks, but also individual, social and institutional vulnerabilities for adolescents33 Fontes MB, Crivelaro RC, Scartezini AM, Lima DD, Garcia AA, Fujioka RT. Determinant factors of knowledge, attitudes and practices regarding STD/AIDS and viral hepatitis among youths aged 18 to 29 years in Brazil. Cien Saude Colet. 2017 abr;22(4):1343-52. http://dx.doi.org/10.1590/1413-81232017224.12852015. PMid:28444057.
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4 Calazans GJ, Pinheiro TF, Ayres JRCM. Vulnerabilidade programática e cuidado público: Panorama das políticas de prevenção do HIV e da Aids voltadas para gays e outros HSH no Brasil. Sex Salud Soc. 2018;(29):263-93. http://dx.doi.org/10.1590/1984-6487.sess.2018.29.13.a.
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-55 Kinalski DDF, Kleinubing RE, Bick MA, Langendorf TF, Padoin SMM, Cardoso PC. Line of care for children and teenagers living with HIV: participatory research with professionals and managers. Esc Anna Nery. 2021;25(2):e20200266. http://dx.doi.org/10.1590/2177-9465-ean-2020-0266.
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Regarding prevention programs, the Programa Saúde na Escola – PSE (Health Program at School, in free translation) stands out as an interest related to the object of study. Developed under the intersectoral policy by the Ministry of Health and of Education in accordance with the priority strategies of the Política Nacional de Promoção da Saúde – PNPS (National Health Promotion Policy), educational actions are carried out by Family Health teams and by professionals from schools with a focus on health of children and adolescents66 Silva AA, Gubert FA, Barbosa-Filho VC, Freitas RWJF, Vieira-Meyer APGF, Pinheiro MTM et al. Ações de promoção da saúde no Programa Saúde na Escola no Ceará: contribuições da enfermagem. Rev Bras Enferm. 2021;74(1):e20190769. http://dx.doi.org/10.1590/0034-7167-2019-0769. PMid:33787775.
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In this sense, it is assumed that understanding how adolescents think within their reality, the school enables health promotion, as some common-sense knowledge can influence changes in attitudes towards prevention. Thus, research that adopts the Theory of Social Representations (TSR) as a theoretical-methodological framework77 Jodelet D. O movimento de retorno ao sujeito e a abordagem das Representações Sociais. Sociedade e Estado, Brasília. 2009 set/dez;24(3):679-712. http://dx.doi.org/10.1590/S0102-69922009000300004.
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can contribute to these ends.

This study aimed to understand the social representations of adolescents about vulnerabilities and risks of contracting HIV/AIDS in sexual relationships.

METHOD

Qualitative, exploratory and descriptive study guided by the Theory of Social Representations (TSR) with a procedural approach, which starts from the definition of social representations as a form of common-sense knowledge, shared and socially elaborated, which allows the construction of a common reality for individuals belonging to a social group77 Jodelet D. O movimento de retorno ao sujeito e a abordagem das Representações Sociais. Sociedade e Estado, Brasília. 2009 set/dez;24(3):679-712. http://dx.doi.org/10.1590/S0102-69922009000300004.
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The research was carried out in a public school of reference for full-time high school, in the city of Recife, Pernambuco, Brazil, selected for being part of the Programa Saúde na Escola – PSE (School Health Program) and the actions of an extension project carried out by the Study and Research Group on Epistemology and Fundamentals of Care in Health and Nursing of the University of Pernambuco (UPE), Faculty of Nursing Nossa Senhora das Graças (FENSG).

The inclusion criteria were being regularly enrolled in high school and being an adolescent. In this study, adolescents were considered to be those aged between 12 and 18 years old, as established by the Estatuto da Criança e do Adolescente – ECA (Brazilian Child and Adolescent Statute), Law 8.069, of 199088 Lei 8.069, de 13 de julho de 1990 (BR). Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [periódico na internet], Brasília (DF), 1990 [citado fev 01 2021]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8069.htm
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. The exclusion criteria consist of being a student who does not have a free timetable of school activities to participate in the research. It is noteworthy that adolescents of both sexes, aged between 17 and 18 years, participated in the study, due to the greater availability of time in the second and third year classes of high school, the expected age group of these series.

As for the operationalization of data collection, it began in May and was completed in October 2016, after an approach with the school’s pedagogical coordinator to enter the field and indicate the moments for the research team to make the invitations to the students of the two classes of the first and second year and one class of the third year of high school.

In the initial stage of the research, after the invitation and use of the do Termo de Assentimento Livre e Esclarecido – TACLE (Free and Informed Assent Term, in free translation) that was signed by the adolescents and the Termo de Consentimento Livre e Esclarecido – TCLE (Free and Informed Consent Term) by the guardians, when under 18 years of age, we proceeded to the individual interview technique with 15 students, in order to access the information necessary to describe the sociodemographic profile of the study participants, such as age, gender, ethnicity or race, place of residence, who they live with, working conditions and questions elaborated by the researchers related to the research topic: Tell us what you know about HIV? Can you tell us how HIV is transmitted? How did you get information about HIV? The interviews were conducted from June to August 2016 by a master’s student in a private room with an average duration of 22 minutes.

In the next step, the objective was to deepen the theme and, for this, the focus group technique was used, this time, of the 15 students, only eight remained available to participate in the study. Data were collected until saturation, that is, until reaching the proposed objectives99 Oliveira DC. Análise de conteúdo temático-categorial: uma técnica maior nas pesquisas qualitativas. In: Lacerda MR, Costenaro RGS, editores. Metodologia da pesquisa para a Enfermagem e Saúde: da teoria à prática. Porto Alegre: Moriá; 2016. p. 481-511.-1010 Medeiros HP, Teixeira E. Metodologia da pesquisa para a enfermagem e saúde: resenha de livro. Rev Bras Enferm. 2016;69(5):1000-1. http://dx.doi.org/10.1590/0034-7167-2015-0135.
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. Three meetings were held from September to October 2016, with an average duration of one hour and forty minutes for each meeting, organized based on the encouraging propositions: talk about what you understand about the risks of contracting a disease through sex (sexual relations); talk about what you know about HIV and AIDS; and the guiding question: What are the risks of contracting HIV and AIDS during sexual intercourse?

In addition to the adolescents, two master’s students in nursing and one master’s student in adolescent health were present at the meetings. To favor the connection with the teenagers, and encourage participation, different group dynamics and recreational resources were carried out, such as the elaboration of parodies to the “Brega” songs (Cringe songs, in free translation), a popular local genre. Many of these songs are criticized for their sexual and erotic content, however they are appreciated by teenagers in the region. All meetings took place in a private room provided by the school.

The interviews and meetings were recorded in digital format and later transcribed in full, however, participants were not asked to check the texts, so that participation in the following meetings was not compromised, due to shame or inhibition. To ensure anonymity, the letter “S” was chosen to refer to “student”, followed by the number corresponding to the sequence of interviews and focus groups.

Data analysis was performed with the support of the QSR Nvivo Software11, using the thematic-categorial content analysis technique77 Jodelet D. O movimento de retorno ao sujeito e a abordagem das Representações Sociais. Sociedade e Estado, Brasília. 2009 set/dez;24(3):679-712. http://dx.doi.org/10.1590/S0102-69922009000300004.
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. In the first stage, called pre-analysis, the corpus was prepared following the software specifications. In the next step, the exploration of the material, the units of meaning were formed, identifying the intermediate elements of analysis and creating nodes to allocate the analyzed excerpts. Categories and themes emerged in order to allow the reorganization of social thinking about the social representations of adolescents regarding vulnerabilities and risks of contracting HIV/AIDS in sexual relations, interpreted in the light of TSR and relevant literature, characterizing the last stage, treatment of results99 Oliveira DC. Análise de conteúdo temático-categorial: uma técnica maior nas pesquisas qualitativas. In: Lacerda MR, Costenaro RGS, editores. Metodologia da pesquisa para a Enfermagem e Saúde: da teoria à prática. Porto Alegre: Moriá; 2016. p. 481-511.

10 Medeiros HP, Teixeira E. Metodologia da pesquisa para a enfermagem e saúde: resenha de livro. Rev Bras Enferm. 2016;69(5):1000-1. http://dx.doi.org/10.1590/0034-7167-2015-0135.
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-1111 Jodelet D. Ponto de vista: sobre o movimento das representações sociais na comunidade científica brasileira. Temas Psicol. 2011;19(1):19-26..

The project was submitted to the Research Ethics Committee of the University of Pernambuco CAAE: 53907716.7.0000.5192, and after obtaining the assent on May 9, 2016, with the number 1.535.999, the collection began.

RESULTS

To know the context of life of these adolescents and support the understanding of their social representations about the vulnerabilities and risks of contracting HIV/AIDS in sexual relations, the characterization of the participants was carried out and it was identified that they were aged between 17 and 18 years, 13 (93.4%) were 18 years old, nine (60%) were male. As for the color or ethnicity of the participants, there was a greater number of declared browns, totaling 12 (80.2%) adolescents.

A high percentage of adolescents live on the outskirts of the city of Recife 11 (73.3%). In the question regarding who the teenager lives with, only five (33.4%) lived with both parents. Related to work activities, one (6.6%) worked, helping the mother in her respective job.

When asked about how the virus is transmitted 14 (93.4%) responded that through sexual intercourse or sharing syringes and needles, one (6.6%) responded that through kissing on the mouth and sexual intercourse. With regard to the cure, 14 (93.4%) agreed that there is still no cure for HIV/AIDS.

As for the data analyzed using the Nvivo 11 software, 513 registration units (RU) were identified, divided into two categories with three themes each, presented below.

Risks of contracting HIV/AIDS during sexual intercourse

The category encompasses the verbalizations referring to the risks of contracting HIV/AIDS during sexual intercourse, which for the adolescents who participated in the study include: not using a condom, having used alcohol and/or drugs, and having sex with several partners. As shown in Figure 1.

Figure 1
Organizational chart of the category risks of contracting HIV/AIDS during sexual intercourse. Recife, PE, Brazil, 2017.

For adolescents, the risk of contracting HIV during sexual intercourse is related to not using a condom, and as for the reasons for not using it, it was possible to understand that they involve gender issues such as sexual pleasure for male adolescents and women’s difficulties to carry a condom with them.

[...] if you don’t carry a condom... you have to police yourself.... (S1-focus group)

A person who goes out with a condom... one of many... because the person goes to the club... and most of them there... go to hook up with everyone ((slang related to the search for sexual partners)) mainly... men [...] men, often, act forgetful... they say no... because sex without a condom is better... they are more pleasurable.... than this than that.... A woman won’t carry it... I’ve never heard at a club... a woman took a condom, specially because there is a taboo on female condoms [...] (S2 – focus group).

From the adolescents’ statements, it is understood that even knowing the risk factors for contracting HIV through sexual intercourse, they expose and express that they do not protect themselves because of different psycho-emotional and social factors. Among these factors, one which was found, considering the importance of having sex without a condom, even in view of the knowledge of the risk that this act represents for HIV transmission, is the trust they place in their partner or the concept of fidelity and, therefore, they do not use condoms as a demonstration of this loving or romantic relational feeling.

You have to have confidence... to have sex... or because you like the person... that’s all [...] (S4 – focus group).

[…] if it’s with my girlfriend, I don’t care ((for the use of condoms)) […] because we’ve already dated […] we have a closed relationship…(S7-individual interview).

Study participants believe the disease may be a result of infidelity between couples.

[…] she’s married with a good person… but she’s not satisfied with what she has and goes looking outside and ends up getting a disease and infecting those of her house… to the wife or husband and keeps spreading. (S8-focus group).

[...] she said that ((with regard to condom use)) she said that you might think that your partner might be being faithful... but he may not be faithful and you could get a disease... because of him... (S5-focus group).

Another reason, in addition to the romantic one, was the rush to consolidate the sexual act. In this approach, adolescents offer greater priority to having sex without thinking about the consequences after the accomplished act, since the intensity of the moment is greater for them than the results they can generate, as expressed in the statements.

[…] but there are people who, at the moment ((of sexual intercourse)) don’t think straight […] you can’t think about stopping […] nor can you think about any (swear word) of any protection. (S4-focus group).

There are girls that you keep trying to get laid with and they don’t want to… so, when you get to it, you won't stop to think about the (swear word) condom. (S6-focus group).

In the same category, the theme of having sex with several partners or frequent change of sexual partners is identified by adolescents as a risk for contracting HIV/AIDS, as expressed in the following speeches, while the contradiction of having a single partner was also revealed as a risk, when there is no condom use, as revealed in the previous theme.

[...] having sex with people you don’t know[...] you don't know her or his sexual health history so you can have sex [...] hanging out with several guys ((slang for boys or men)) in one night.... or as with several girls in one night[...] know that I don’t do that.... (laughs)... (S4-focus group).

[...] it’s staying with a lot of guys ((slang for boys or men)) [...] or with a lot of girls [...] it’s being exposed [...] all night having sex with many women or a woman can spend all night having sex with several men.... that’s it... (S1-individual interview).

As for the factors that influence having sex and not using condoms, adolescents report that the use of alcohol and other drugs represents a risk for contracting HIV/AIDS, given the number of side effects that these substances cause.

[…] often, young people… have sex and, in addition to having sex, they can use drugs… the drug along with sexual intercourse… and this also allows for many diseases[…] (S1-individual interview).

[…] they would be at risk of contracting a sexually transmitted disease by drinking heavily. (S3-focus group)

[…] I would be exposed when I drink a lot… (S6-individual interview).

Participants present drug use as a problem that can lead to consequences and pose health risks, including HIV.

From the risks of contracting HIV/AIDS during sexual intercourse to vulnerabilities

The category discusses that the consecutive meetings in the focus group allowed a deeper understanding of the social representations of adolescents, revealing an increase in the importance of psychosocial dimensions that express a notion of passing from the concern about the risks of contracting HIV/AIDS in sexual relations to the representations of health vulnerabilities, according to the adolescents who participated in the study. As shown in Figure 2.

Figure 2
Organizational chart of the category from the risks of contracting HIV/AIDS in sexual relations to vulnerabilities, Recife, PE, Brazil, 2017.

Adolescents who participated in the study show that other elements and aspects of life, in addition to biological ones, are relevant when the topic is sexuality. Thus, even without evoking the term health vulnerability, its concept can be understood in the students’ statements, when they state individual involvement, such as behaviors and the ability to grasp available information about HIV; lack of conversations with parents and family; and social, such as those related to poverty and economic problems, as well as difficulties in accessing health services and health education at school.

About the difficulties in accessing health services, the statements address the lack of knowledge about the care provided in the HIV care network, highlighting from the testing services to the science of free treatment. Participants highlight the idea that there are many difficulties for people living with HIV (PLHIV) to have access to the Unified Health System (Sistema Único de Saúde – SUS) in Brazil.

[…] many young people do not have the knowledge of how to do it and how not to do it ((safe sex)) … they end up transmitting the disease and not knowing how to take the tests to be able to prevent themselves… to be able to take care of themselves… even passing it on to other young people[ …] (S2-focus group).

[…] to treat it ((AIDS)) is difficult because the health system… despite being great… the importance of the SUS… is still very precarious… so to treat this thing ((AIDS)) I think of it being very difficult […] (S8-focus group).

In the participants’ speeches, other highlights linked to the difficulties in accessing health services are the difficulties in carrying out sex education at school, ranging from political-ideological aspects, religious to immaturity to address these issues seriously in different environments, including the school.

[...] an important thing is to discuss sexual intercourse at school... because many ((girls)) are in their first year of high school and already have sexual intercourse.... but they don’t know the preventive methods [...] they don’t go to the gynecologist or have never been to one... they don’t know that they have to undergo an exam every year ((refers to the preventive exam for cervical cancer)) [...] and other things[...] the State doesn’t want them to learn about this... they don’t want us to study gender... imagine sex education... (S4-focus group).

[...] they think that if the teacher... explains about sex... about diseases... about gender, which is a subject that we should know... they are influencing us [...] there is.... at school... ((School Health Program)) education at school.... but it is not so informative.... we live in a society that is fundamentally religious... some not as much as others... but our society is religious[...] but we feel the weight of religion a lot... so I think it has a lot of influence on the taboo[...] (S3-focus group).

[...] adolescents have been showing very fast sexual development very early and in schools they don’t talk.... like when they’re in the seventh or eighth grade, there are already girls who have sex and nobody talks because it’s a taboo subject.... so much so that to present a work on STD ((sexually transmitted diseases)) at school, no one is mature for anything.... it was one person presenting and the others laughing... everyone laughing.... the person arrived with a model and a condom... and people make it.... everybody knows everybody is aware of it... but because the subject is so controversial... everybody gets a little cornered... (S2-focus group).

The topic of having conversations with parents or family members was highlighted in the adolescents’ statements, with the compromised family relationship being presented by them as responsible for the lack of knowledge or non-adoption of prevention.

[…] I didn’t talk to my parents myself… they didn’t sit down and say let’s talk… they didn’t sit down… I learned through one and another […] the confidence they have at home and, often, when their parents let them like whatever... the girl goes the wrong way... the boy goes the wrong way... they go because of what they hear in the streets... at school it’s you go girl... you go boy... it’s always like this, they’ll never say girl think straight about what you are doing... it’s not like that… no… it’s always, you don’t want to? So, go!… later when it gets real ((slang to face reality)) it’s already… a pregnancy… a disease. (S3-focus group).

The compromising of family participation or lack of conversations with parents is even more critical for female adolescents. All participants reported that parents do not usually talk about sex and issues related to the prevention of pregnancy and sexually transmitted diseases, as shown in the following statements.

[…] my case, for example, I have two male brothers and me, a girl… so, my mother sits at the table and talks with my two brothers […] she tells me to close the door… ((she reports that the mother says)) “- You can’t listen… because you’re a woman!” […] (S1-focus group).

[…] she ((the mother)) never sat down with me […] to say: having sex is this, this and this… and I ended up finding things out… but with my brother she came and said… a condom is blah, blah, put it that way… but I learned it myself… and when she found out that I had lost my virginity, she ((reports that the mother said)) “- Ah… you need to get married” […] (S3-focus group).

[…] every week she ((the mother of a male adolescent)) would give me three or four condoms… no kidding! (S7-focus group).

As for the presence of the theme being poor, it would appear in the results in a controversial way. The adolescents in the study, although living on the outskirts of the city, attribute to poor young people the highest number of cases of sexually transmitted diseases. However, they do not reveal social perception about this health vulnerability for themselves.

[…] it may seem a little prejudiced, but normally it is always the poorest layer that contains the most of these diseases… (S4-focus group).

[…] not being prejudiced… I also think that you are also prejudiced… but… the slums and the suburbs… who do not learn this easily ((refers to protection and prevention)) (S3-focus group).

Adolescents report that being poor can lead other adolescents to have sex without using condoms, even considering that these statements can be prejudiced.

DISCUSSION

Adolescents’ social representations of the risks of contracting HIV/AIDS in sexual relationships refer to representations and representational contents such as not using condoms, having used alcohol and/or drugs and having several sexual partners, presented as results in the first category.

As for not using condoms, the study comprehended that representation involves emotional, affective and social dimensions, such as trust in the partner and the demonstration of this loving or romantic feeling when negotiating the use with partners. Therefore, they reported not using condoms in sexual relations with steady partners, boyfriends and girlfriends, even knowing the importance of its use, as was also found by other authors1212 Correa LDR, Gonzaga LL. Rejeição do uso de camisinha por adolescentes: uma perspectiva a partir da zona muda das representações sociais. Rev Espaço Pedagógico. 2018;25(2):472-87..

However, it was more common among male adolescents that the reason for not using it is the highest priority to have sex immediately, without thinking about the consequences, since sexual intensity and pleasure represent their greatest idealized goals, corroborating with the findings of a study carried out with high school students from a public school in Fortaleza, Ceará, Brazil1313 Bezerra EO, Pereira MLD, Chaves ACP, Monteiro PV. Social representations of teenagers on sexual relations and the use of condoms. Rev Gaúcha Enferm. 2015 mar;36(1):84-91. http://dx.doi.org/10.1590/1983-1447.2015.01.45639. PMid:26098807.
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As for having multiple partners, the representations refer to promiscuity and the deviant experience of sexuality, consolidating normative ideals about sex, present in their realities, as well as the need for group affirmation in the process of development of sexuality and in the biopsychosocial context1313 Bezerra EO, Pereira MLD, Chaves ACP, Monteiro PV. Social representations of teenagers on sexual relations and the use of condoms. Rev Gaúcha Enferm. 2015 mar;36(1):84-91. http://dx.doi.org/10.1590/1983-1447.2015.01.45639. PMid:26098807.
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. In this context, one should pay attention to the fact that the theme does not refer to the non-use of condoms with these various partners, but rather attributes the risk to the fact of having many partners or having many sexual relations in the same night.

These findings are very worrying and reveal the need to discuss the factors associated with condom use among adolescents in order to plan interventions. About this, a population-based survey revealed that among those who started sexual activity after 15 years of age; who used a condom in the first sexual intercourse; and who have access to free condoms, the use was more frequent1414 Gutierrez EB, Pinto VM, Basso CR, Spiassi AL, Lopes MEBR, Barros CRDS. Fatores associados ao uso de preservativoem jovens – inquérito de base populacional. Rev Bras Epidemiol. 2019;22:e190034. http://dx.doi.org/10.1590/1980-549720190034. PMid:31038615.
http://dx.doi.org/10.1590/1980-549720190...
.

As for having used alcohol and/or drugs as one of the risks for contracting HIV/AIDS, the adolescents participating in this study show that the understanding of social representations of adolescents on the issue of alcoholic beverages and, more precisely, on alcoholism favors to know the understanding they have about this psychosocial object in their daily lives1515 Pereira ASK, Medeiros ED, Fernandes AL, Pereira BR. Representações sociais do álcool entre estudantes universitárias brasileiras. Psicol Conoc Soc. 2019 jun;9(1):161-81., and, in turn, how they influence their practices and choices about the use of condoms in sexual relations.

In Brazil, a review study that brought together research on the associated factors and sexual behaviors that contribute to sexually transmitted diseases among adolescents found that the use of substances such as alcohol and drugs increases the incidence of unprotected sex1616 Moura LR, Torres LM, Cadete MMM, Cunha CF. Factors associated with health risk behaviors among Brazilian teenagers: an integrative review. Rev Esc Enferm USP. 2018;52:e03304. PMid:29668787..

The finding is repeated in the international context, a study on risk behavior related to the use of condoms and contraceptives among sexually active high school students in the United States (USA) showed that the prevalence of condom use was consistently lower among students who consumed drugs and other psychoactive substances such as alcohol1717 Szucs LE, Lowry R, Fasula AM, Pampati S, Copen CE, Hussaini KS et al. Condom and contraceptive use among sexually active high school students – youth risk behavior survey, United States, 2019. MMWR Suppl. 2020;69(1):11-8. http://dx.doi.org/10.15585/mmwr.su6901a2. PMid:32817600.
http://dx.doi.org/10.15585/mmwr.su6901a2...
.

It is noteworthy that the changes in the understanding of the risks of contracting HIV/AIDS in sexual relations to the representations of vulnerabilities were being presented by the study participants, as the meetings promoted for the focus groups allowed to deepen the data from the individual interviews of the initial meetings.

Thus, the second category, called: from the risks of contracting HIV/AIDS in sexual relations to vulnerabilities, which involve having difficulties in accessing health services and sexual education in schools; not having conversations with parents or family members; and being poor, presented as themes in the results.

One of the main and most notable changes in the epidemiological profile of the disease started the process of transforming the use of the concept of risk group, then of risk behavior to vulnerabilites44 Calazans GJ, Pinheiro TF, Ayres JRCM. Vulnerabilidade programática e cuidado público: Panorama das políticas de prevenção do HIV e da Aids voltadas para gays e outros HSH no Brasil. Sex Salud Soc. 2018;(29):263-93. http://dx.doi.org/10.1590/1984-6487.sess.2018.29.13.a.
http://dx.doi.org/10.1590/1984-6487.sess...
. Knowledge about the critical elements of vulnerabilities to HIV is gender, social class and age group. They admit the assertion that the virus is a social phenomenon linked to the experience of human sexuality1818 Souza SO, Cunha PA, Almeida SC, Ribeiro SCP, Marcelly SMM, Matos MM. Iniquidades de género e vulnerabilidade às IST/HIV/AIDS em adolescentes de assentamento urbano: um estudo exploratório. Cienc Enferm. 2020;26:12.-1919 Góis ARS, Oliveira DC, Costa SFG, Oliveira RC, Abrão FMS. Representações sociais de profissionais da saúde sobre as pessoas vivendo com HIV/Aids. Av en Enfermería. 2017;35(2):169-78. http://dx.doi.org/10.15446/av.enferm.v35n2.59636.
http://dx.doi.org/10.15446/av.enferm.v35...
.

There are three complex and interdependent dimensions in the notion of vulnerabilities: programmatic or institutional, social and individual. The latter is subdivided into two levels, one cognitive and one behavioral, which can be related to the results of this study, to the difficulties in transforming knowledge about risks into preventive attitudes22 Ayres JR, Castellanos MEP, Baptista TWF. Entrevista com José Ricardo Ayres. Saude Soc. 2018 jan;27(1):51-60. http://dx.doi.org/10.1590/s0104-12902018000002.
http://dx.doi.org/10.1590/s0104-12902018...
. The programmatic and social dimensions of vulnerabilities were also addressed by the study participants, when they presented difficulties in accessing health services for testing, counseling and distribution of supplies and treatments, and for sex education in schools.

As for sex education in schools, Brazil ratified that partnerships with schools and communities should be carried out by the Family Health Strategy (FHS) to reduce vulnerabilities among adolescents. However, political-ideological aspects have compromised its realization over the years2020 Moreira P, Reis T, Mendes R, Menezes A. HIV vulnerability among teenagers attending to public schools. RPCFO. 2019 jul;11(4):868-72. http://dx.doi.org/10.9789/2175-5361.2019.v11i4.868-872.
http://dx.doi.org/10.9789/2175-5361.2019...
, and this was also mentioned by the adolescents in the study.

It is noteworthy that a survey conducted with students in Ethiopia considered highly recommended to include sexual and reproductive health in the educational curriculum2121 Nigussie T, Yosef T. Knowledge of sexually transmitted infections and its associated factors among polytechnic college students in Southwest Ethiopia. Pan Afr Med J. 2020;37:68. http://dx.doi.org/10.11604/pamj.2020.37.68.22718. PMid:33244331.
http://dx.doi.org/10.11604/pamj.2020.37....
. Corroborating the findings of this study, when it points out that adolescents learn about the vulnerabilities and risks among themselves more than they do in family or with teachers. Thus, on the subject, some researchers describe that strategies that promote the protagonism of students themselves in the educational process, such as the use of active methodologies and peer education, are more effective2222 Barreto VP, Inácio JO, Silva BCO, Aquino ARG, Marques CC, Feijão AR. Peer education as strategy for HIV/AIDS prevention among teenagers. Saúde Pesqui. 2020;13(2):253-63. http://dx.doi.org/10.17765/2176-9206.2020v13n2p253-263.
http://dx.doi.org/10.17765/2176-9206.202...
-2323 Carvalho ACT, Silva DMR, Brandão-Neto W, Pereira EBF, Menezes MLN, Aquino JM. Percepções de adolescentes escolares do sexo masculino quanto ao cuidado à sua saúde. Enferm Actual Costa Rica. 2019 dez;(37):80-94..

It is noteworthy that this notion of vulnerabilities allows the proposition that public policies can affect HIV prevention, considering that knowledge of risks alone does not imply changes in attitude and behavior, given the many biopsychosocial factors that influence, as pointed out by the findings from a longitudinal study conducted in Zimbabwe2424 Schaefer R, Thomas R, Maswera R, Kadzura N, Nyamukapa C, Gregson S. Relationships between changes in HIV risk perception and condom use in East Zimbabwe 2003-2013: population-based longitudinal analyses. BMC Public Health. 2020;20(1):756. http://dx.doi.org/10.1186/s12889-020-08815-1. PMid:32448365.
http://dx.doi.org/10.1186/s12889-020-088...
.

Other studies consider it crucial to involve parents, family members and schools in promotion and prevention actions, considering that adolescents receive many inadequate guidance from friends and unreliable sources2020 Moreira P, Reis T, Mendes R, Menezes A. HIV vulnerability among teenagers attending to public schools. RPCFO. 2019 jul;11(4):868-72. http://dx.doi.org/10.9789/2175-5361.2019.v11i4.868-872.
http://dx.doi.org/10.9789/2175-5361.2019...
,2222 Barreto VP, Inácio JO, Silva BCO, Aquino ARG, Marques CC, Feijão AR. Peer education as strategy for HIV/AIDS prevention among teenagers. Saúde Pesqui. 2020;13(2):253-63. http://dx.doi.org/10.17765/2176-9206.2020v13n2p253-263.
http://dx.doi.org/10.17765/2176-9206.202...
. This corroborates the findings of this study regarding lack of conversations with parents or family members about the topic. In this regard, the social vulnerability expressed by a compromised family relationship was even more intense among female adolescents.

From another social vulnerability, understood from the speeches of the adolescents who participated in the study, representations anchored by them regarding poverty (being poor) emerged. Adolescents represent the same as a factor related to HIV contamination or contagion, since, according to the participants’ perspective, poor people do not have adequate education or sufficient economic resources for protection and, therefore, would be the most susceptible group to HIV or other Sexually Transmitted Infections (STIs).

However, even within this social group in relation to the economic aspects investigated, they still do not represent themselves as vulnerable because they do not recognize themselves as such2525 Herzog L. Teoria do reconhecimento e democracia econômica: potenciais não exauridos. Civitas. 2018;18(3):523-38. http://dx.doi.org/10.15448/1984-7289.2018.3.29550.
http://dx.doi.org/10.15448/1984-7289.201...
.

FINAL CONSIDERATIONS AND IMPLICATIONS FOR PRACTICE

The study allowed us to understand that the social representations of adolescents about vulnerabilities and risks to contract HIV/AIDS in sexual relations are related to not using a condom, for issues such as sexual pleasure for male adolescents and to the female difficulties in carrying it with them.

Having used alcohol and/or drugs, having several partners, having difficulties in accessing health services and sex education in schools; and not having conversations with parents or family members, the latter being more critical for female adolescents, are other vulnerabilities and risks that emerged in the study.

It is noteworthy that the understanding of the social representations of adolescents revealed an increase in the importance of psycho-emotional and social dimensions that express a notion of transition from concern about the risks of contracting HIV/AIDS in sexual relationships to representations of health vulnerabilities.

The results of this study propose as a practical implication the prioritization of public policies focused on emotional, affective and social dimensions in the environment in which representations circulate, considering that in this scenario they may be able to interfere in the reality of adolescents.

As for the limitations of the study, those related to the size of the sample were considered, which from 15 participants in the period of individual interviews was reduced to eight in the focus group meetings, due to the availability of students, considering that it is a school of integral education. However, to minimize the effects of this limitation, the data collection period was extended and all students' participations were scheduled in advance, in order to prevent the loss of new participants at each meeting. What made it possible to keep the participation of the same eight students for all subsequent meetings.

  • FINANCIAL SUPPORT This work was carried out with the support of the Coordination for the Improvement of Higher Education Personnel - Brazil (CAPES) - Financing Code 001, in the Masters scholarship modality granted to Esmelsy Cabrera Garcia, in the period from 2015 to 2017.

REFERÊNCIAS

  • 1
    Brasil. Ministério da Saúde. Boletim Epidemiológico HIV e Aids-2018 [Internet]. 2018 [citado fev 01 2021]. Disponível em: http://www.aids.gov.br/pt-br/pub/2018/boletim-epidemiologico-hivaids-2018
    » http://www.aids.gov.br/pt-br/pub/2018/boletim-epidemiologico-hivaids-2018
  • 2
    Ayres JR, Castellanos MEP, Baptista TWF. Entrevista com José Ricardo Ayres. Saude Soc. 2018 jan;27(1):51-60. http://dx.doi.org/10.1590/s0104-12902018000002
    » http://dx.doi.org/10.1590/s0104-12902018000002
  • 3
    Fontes MB, Crivelaro RC, Scartezini AM, Lima DD, Garcia AA, Fujioka RT. Determinant factors of knowledge, attitudes and practices regarding STD/AIDS and viral hepatitis among youths aged 18 to 29 years in Brazil. Cien Saude Colet. 2017 abr;22(4):1343-52. http://dx.doi.org/10.1590/1413-81232017224.12852015 PMid:28444057.
    » http://dx.doi.org/10.1590/1413-81232017224.12852015
  • 4
    Calazans GJ, Pinheiro TF, Ayres JRCM. Vulnerabilidade programática e cuidado público: Panorama das políticas de prevenção do HIV e da Aids voltadas para gays e outros HSH no Brasil. Sex Salud Soc. 2018;(29):263-93. http://dx.doi.org/10.1590/1984-6487.sess.2018.29.13.a
    » http://dx.doi.org/10.1590/1984-6487.sess.2018.29.13.a
  • 5
    Kinalski DDF, Kleinubing RE, Bick MA, Langendorf TF, Padoin SMM, Cardoso PC. Line of care for children and teenagers living with HIV: participatory research with professionals and managers. Esc Anna Nery. 2021;25(2):e20200266. http://dx.doi.org/10.1590/2177-9465-ean-2020-0266
    » http://dx.doi.org/10.1590/2177-9465-ean-2020-0266
  • 6
    Silva AA, Gubert FA, Barbosa-Filho VC, Freitas RWJF, Vieira-Meyer APGF, Pinheiro MTM et al. Ações de promoção da saúde no Programa Saúde na Escola no Ceará: contribuições da enfermagem. Rev Bras Enferm. 2021;74(1):e20190769. http://dx.doi.org/10.1590/0034-7167-2019-0769 PMid:33787775.
    » http://dx.doi.org/10.1590/0034-7167-2019-0769
  • 7
    Jodelet D. O movimento de retorno ao sujeito e a abordagem das Representações Sociais. Sociedade e Estado, Brasília. 2009 set/dez;24(3):679-712. http://dx.doi.org/10.1590/S0102-69922009000300004
    » http://dx.doi.org/10.1590/S0102-69922009000300004
  • 8
    Lei 8.069, de 13 de julho de 1990 (BR). Dispõe sobre o Estatuto da Criança e do Adolescente e dá outras providências. Diário Oficial da União [periódico na internet], Brasília (DF), 1990 [citado fev 01 2021]. Disponível em: http://www.planalto.gov.br/ccivil_03/leis/l8069.htm
    » http://www.planalto.gov.br/ccivil_03/leis/l8069.htm
  • 9
    Oliveira DC. Análise de conteúdo temático-categorial: uma técnica maior nas pesquisas qualitativas. In: Lacerda MR, Costenaro RGS, editores. Metodologia da pesquisa para a Enfermagem e Saúde: da teoria à prática. Porto Alegre: Moriá; 2016. p. 481-511.
  • 10
    Medeiros HP, Teixeira E. Metodologia da pesquisa para a enfermagem e saúde: resenha de livro. Rev Bras Enferm. 2016;69(5):1000-1. http://dx.doi.org/10.1590/0034-7167-2015-0135
    » http://dx.doi.org/10.1590/0034-7167-2015-0135
  • 11
    Jodelet D. Ponto de vista: sobre o movimento das representações sociais na comunidade científica brasileira. Temas Psicol. 2011;19(1):19-26.
  • 12
    Correa LDR, Gonzaga LL. Rejeição do uso de camisinha por adolescentes: uma perspectiva a partir da zona muda das representações sociais. Rev Espaço Pedagógico. 2018;25(2):472-87.
  • 13
    Bezerra EO, Pereira MLD, Chaves ACP, Monteiro PV. Social representations of teenagers on sexual relations and the use of condoms. Rev Gaúcha Enferm. 2015 mar;36(1):84-91. http://dx.doi.org/10.1590/1983-1447.2015.01.45639 PMid:26098807.
    » http://dx.doi.org/10.1590/1983-1447.2015.01.45639
  • 14
    Gutierrez EB, Pinto VM, Basso CR, Spiassi AL, Lopes MEBR, Barros CRDS. Fatores associados ao uso de preservativoem jovens – inquérito de base populacional. Rev Bras Epidemiol. 2019;22:e190034. http://dx.doi.org/10.1590/1980-549720190034 PMid:31038615.
    » http://dx.doi.org/10.1590/1980-549720190034
  • 15
    Pereira ASK, Medeiros ED, Fernandes AL, Pereira BR. Representações sociais do álcool entre estudantes universitárias brasileiras. Psicol Conoc Soc. 2019 jun;9(1):161-81.
  • 16
    Moura LR, Torres LM, Cadete MMM, Cunha CF. Factors associated with health risk behaviors among Brazilian teenagers: an integrative review. Rev Esc Enferm USP. 2018;52:e03304. PMid:29668787.
  • 17
    Szucs LE, Lowry R, Fasula AM, Pampati S, Copen CE, Hussaini KS et al. Condom and contraceptive use among sexually active high school students – youth risk behavior survey, United States, 2019. MMWR Suppl. 2020;69(1):11-8. http://dx.doi.org/10.15585/mmwr.su6901a2 PMid:32817600.
    » http://dx.doi.org/10.15585/mmwr.su6901a2
  • 18
    Souza SO, Cunha PA, Almeida SC, Ribeiro SCP, Marcelly SMM, Matos MM. Iniquidades de género e vulnerabilidade às IST/HIV/AIDS em adolescentes de assentamento urbano: um estudo exploratório. Cienc Enferm. 2020;26:12.
  • 19
    Góis ARS, Oliveira DC, Costa SFG, Oliveira RC, Abrão FMS. Representações sociais de profissionais da saúde sobre as pessoas vivendo com HIV/Aids. Av en Enfermería. 2017;35(2):169-78. http://dx.doi.org/10.15446/av.enferm.v35n2.59636
    » http://dx.doi.org/10.15446/av.enferm.v35n2.59636
  • 20
    Moreira P, Reis T, Mendes R, Menezes A. HIV vulnerability among teenagers attending to public schools. RPCFO. 2019 jul;11(4):868-72. http://dx.doi.org/10.9789/2175-5361.2019.v11i4.868-872
    » http://dx.doi.org/10.9789/2175-5361.2019.v11i4.868-872
  • 21
    Nigussie T, Yosef T. Knowledge of sexually transmitted infections and its associated factors among polytechnic college students in Southwest Ethiopia. Pan Afr Med J. 2020;37:68. http://dx.doi.org/10.11604/pamj.2020.37.68.22718 PMid:33244331.
    » http://dx.doi.org/10.11604/pamj.2020.37.68.22718
  • 22
    Barreto VP, Inácio JO, Silva BCO, Aquino ARG, Marques CC, Feijão AR. Peer education as strategy for HIV/AIDS prevention among teenagers. Saúde Pesqui. 2020;13(2):253-63. http://dx.doi.org/10.17765/2176-9206.2020v13n2p253-263
    » http://dx.doi.org/10.17765/2176-9206.2020v13n2p253-263
  • 23
    Carvalho ACT, Silva DMR, Brandão-Neto W, Pereira EBF, Menezes MLN, Aquino JM. Percepções de adolescentes escolares do sexo masculino quanto ao cuidado à sua saúde. Enferm Actual Costa Rica. 2019 dez;(37):80-94.
  • 24
    Schaefer R, Thomas R, Maswera R, Kadzura N, Nyamukapa C, Gregson S. Relationships between changes in HIV risk perception and condom use in East Zimbabwe 2003-2013: population-based longitudinal analyses. BMC Public Health. 2020;20(1):756. http://dx.doi.org/10.1186/s12889-020-08815-1 PMid:32448365.
    » http://dx.doi.org/10.1186/s12889-020-08815-1
  • 25
    Herzog L. Teoria do reconhecimento e democracia econômica: potenciais não exauridos. Civitas. 2018;18(3):523-38. http://dx.doi.org/10.15448/1984-7289.2018.3.29550
    » http://dx.doi.org/10.15448/1984-7289.2018.3.29550

Edited by

ASSOCIATED EDITOR

SCIENTIFIC EDITOR

Publication Dates

  • Publication in this collection
    25 Oct 2021
  • Date of issue
    2022

History

  • Received
    29 Mar 2021
  • Accepted
    29 June 2021
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