Resumo: Objetivo: identificar as práticas sexuais e os cuidados com a saúde sexual de graduandos de enfermagem frente às infecções sexualmente transmissíveis. Método: estudo transversal descritivo quantitativo, realizado em duas instituições de ensino superior do Rio de Janeiro, com 250 estudantes. Para a análise das variáveis empregou-se a estatística descritiva. Resultados: a maioria, 132 (52,8%) tem idades entre 18 – 21 anos; sendo 217 (86,8%) do sexo feminino. Entre os participantes 185 (74.0%) possuem vida sexual ativa. Desses, 113 (61,1%) utilizaram o preservativo na sexarca e 107 (57,8%) informaram fazer uso em todos os intercursos sexuais. Em relação ao cuidado com a saúde, 110 (44,0%) já fizeram teste para detectar o HIV. Entre as mulheres, 125(57,6%) fizeram o exame Papanicolau. Conclusão: pode-se inferir que os graduandos de enfermagem, são vulneráveis às infecções sexualmente transmissíveis e adotam comportamentos de risco em suas práticas sexuais.

Descritores: Vulnerabilidade em saúde; Adulto jovem; Doenças sexualmente transmissíveis; Enfermagem

Resumen: Objetivo: identificar las prácticas sexuales y cuidados con la salud sexual de estudiantes de enfermería frente a las infecciones sexualmente transmisibles. Método: estudio transversal, descriptivo, cuantitativo, realizado en dos instituciones de enseñanza superior de Río de Janeiro, con 250 estudiantes. Para el análisis de las variables se empleó la estadística descriptiva. Resultados: la mayoría de los estudiantes 132 (52,8%) tienen edades entre 18 - 21 años; 217 (86,8%) son del sexo femenino. Entre los participantes, 185 (74.0%) poseen vida sexual activa, de esos 113 (61,1%) utilizaron preservativo en la sexarca y 107 (57,8%) informaron hacer uso en todas las relaciones sexuales. Con relación al cuidado con la salud, 110 (44,0%) ya hicieron prueba para detectar el VIH. Entre las mujeres, 125 (57,6%) hicieron el examen Papanicolau. Conclusión: se puede inferir que los estudiantes de enfermería son vulnerables a las infecciones sexualmente transmisibles y adoptan comportamientos de riesgo en sus prácticas sexuales.

Descriptores: Vulnerabilidad en salud; Adulto joven; Enfermedades sexualmente transmisibles; Enfermería.

Introduction

Sexually Transmitted Infections (STIs) are transmitted primarily through sexual contact and blood and are caused by different etiological agents such as viruses, bacteria and protozoa. STIs are considered a public health problem because they have repercussions on the reproductive health of the population and can cause infertility, fetal loss, premature death, infections in newborns, penile and cervical cancer, and can be a risk factor for infection with human immunodeficiency virus (HIV).^1-2

The onset of sexual life often occurs in youth and the average age of first intercourse is 14.9 years, that is, in adolescence. At the time, cognition and decision-making are still under development, which prompts young people to become more vulnerable and engaging in risky behaviors such as unprotected sex.³

According to the Statute of the Youth, individuals between the ages of 15 and 29 are recognized as young people.⁴Young people go through puberty, adolescence and early adulthood, important phases in life. Youth is a moment of transition, creation of identity, and external changes from puberty. It is not restricted to the biological sphere, but also to social and psychological aspects.⁵

The high incidence of seropositivity for HIV and other STIs in the Brazilian population represents a serious public health problem. Recent research by the Ministry of Health indicates that in the period from 2010 to 2016, a total of 342,531 cases of acquired syphilis were reported. In 2016, most reports occurred in individuals between 20 and 29 years of age, and among young people between 13 and 19 years of age; the latter group has been increasing since 2010.⁶ Research⁷ conducted by the Ministry of Health in collaboration with the Moinhos de Vento Hospital in the city of Porto Alegre - Rio Grande do Sul, with 7,586 participants aged 16 to 25 years, estimated a prevalence of 54.6% for HPV in young people. Among the participants, 38.4% had HPV of high risk for development of cancer.

Studies^2,4 point out that young people assume behaviors considered risky or are unaware of the methods of disease prevention and this makes them vulnerable to infections. Thus, the early onset of sexual activity, the discontinuous or incorrect use of condoms, the use of alcohol and other drugs, the syndrome of normal adolescence, and behaviors influenced by the social environment of the young people are signs that vulnerability is associated with individual, social, economic and cultural factors.^8-9

The term vulnerability arose in the 1990s associated with the HIV epidemic and represents a set of conditions that make individuals susceptible to diseases.¹⁰Vulnerability is related to the concept of social welfare adopted by the State.¹¹ The concept of vulnerability can be understood from three perspectives: individual, social, and programmatic. Individual vulnerability considers the level of information each individual possesses and how that information is assimilated into one's life. Social vulnerability is the set of factors available in society, access to information, services, and culture, among others, that can be used by the citizen. In turn, programmatic vulnerability refers to political actions and health services implemented to reduce and control diseases.¹²

Socioeconomic, cultural and behavioral aspects are directly related to the vulnerability of a group before STIs. Thus, investigations on the subject contribute to a better understanding of the phenomenon and to the determination of strategic actions to reduce these diseases. Actions for STI prevention include reducing the number of sexual partners, continued use of condoms, search for health care as soon as signs and symptoms appear, and periodic examinations, among others.¹

In this perspective, the present study aims to identify the sexual practices and care measures related to sexual health of nursing students before sexually transmitted infections.

Method

This is a cross-sectional, descriptive, quantitative study conducted in the period 2013/2014, in two higher education institutions located in the city of Rio de Janeiro. Two hundred and fifty (250) university students participated, 135 from a public university and 115 from a private institution.

The sample was of the intentional, non-probabilistic type, composed only of students of the first and second academic semesters of the nursing course. The choice for the initial semesters is justified by the fact that when young people start higher education, they are inserted subjects of a basic curriculum, such as physiology, biochemistry, anatomy and others, and have little information about ways of preventing diseases. There was an interest, thus, in capturing the information before young people had access to such content.

The inclusion criteria were: nursing students of both sexes, aged 18 to 29, regularly enrolled in the nursing course of the institutions, and belonging to the first and second academic semesters. Students who were not present during the data collection period were excluded.

After identification of participants that met the inclusion criteria, a structured questionnaire was applied with 50 closed questions addressing socioeconomic and behavioral variables, and variables related to knowledge and prevention of STIs. Data collection took place during the intervals of classes with the purpose of not disturbing the dynamics in the classroom, and the participants previously signed the Informed Consent Term (ICT), as foreseen in Resolution 466/2012.

The data collection instrument (DCI) was previously tested in a pilot test with 10 university students to verify the objectivity, clarity and relevance to the proposed objectives. After this, adjustments were made in the questionnaire and the instruments used in the test, discarded. It is worth mentioning that the DCI was adapted and elaborated based on an investigation by the Ministry of Health entitled "Research on Behaviors, Attitudes and Practices of the Brazilian Population".

The data was released in the Excel software of the Microsoft Office 2013 for Windows. The variables selected, for the most part, were qualitative and dichotomous. For the analysis, resources of descriptive statistics were used, with univariate analysis, and the results were presented in absolute frequencies and percentages, being discussed in the light of experts on the theme.

The research was previously submitted and approved by the Research Ethics Committees of the institutions that held the research under Opinions number 063/2012 and 327,872/2013.

Results

A total of 250 university students from the nursing course were included in the sample set. Among the participants, more than half were aged between 18 and 21 years, 132 (52.8%). As to gender, 217 (86.8%) were female and 33 (13.2%) were male. Regarding marital status, 130 (52.0%) did not have affective relationships; 67 (26.8%) had stable relationships; 16 (6.4%) lived in an unstable union, and 37 (14.8%) did not answer the question. In the religious aspect, 214 (89.2%) practiced a religion; of these 96 (44.8%) were Catholics.

In the investigated group, 178 (71.2%) lived with their parents, 30 (12.0%) with relatives, 18 (7.2%) with the partner, 13 (5.2%) alone, and 11 (4.4%) with friends. Regarding employment, 171 (68.4%) did not work; of this total, 120 (48.0%) belonged to the public university and 51 (20.4%) to private university.

Among the participants, 185 (74.0%) had active sexual life, and 133 (71.9%) had had their first sexual intercourse between 12 and 18 years. Table 1 presents the sexual practices of university students.

Table 1: Sexual practices of nursing students and condom use. Rio de Janeiro, 2015. N = 185

Sexual Practices	Yes		No		*Ni		Total
Sexual Practices	f	%	f	%	f	%	f	%
Used condoms in the first intercourse	113	61.1	70	38.0	2	1.1	185	100
Used condoms in all sexual intercourses	107	58.0	78	42.2	-	-	185	100
Had sexual relationships with fixed partners in the last year	158	85.4	24	13.0	3	1.6	185	100
Used condoms in sexual relationships with fixed partners	89	56.3	69	43.7	-	-	158	100
Had sexual relationships with casual partners in the last year	46	25.0	136	73.5	3	1.6	185	100
Used condoms in sexual relationships with casual partners	41	89.1	5	11.0	-	-	46	100
Had more than one sexual partner in life	118	64.0	66	35.7	1	0.5	185	100

Note:* Not informed.

Of the 185 participants with sexually active life, 155 (83.8%) were female and 30 (16.2%) were male. Table 2 presents some practices performed by university students (217) as care measures for sexual health and prevention of health problems. It was observed that 89 (41.0%) young people underwent gynecological examination in 2015, 125 (57.0%) underwent a Pap smear examination and 89 (41.0%) underwent HIV testing. Among the 155 sexually active respondents, 12 (7.7%) reported the use of female condoms in sexual intercourse, while 144 (91.0%) reported not having used this method of prevention. Only 2 (1.3%) did not respond to the question.

Table 2: Care practices for sexual health of nursing students. Rio de Janeiro, 2015.

Questions - women only	f	%
Did you take the gynecological examination?
This year	89	41.0
Last year	49	22.6
1 year ago	20	9.2
In the last 2 years	10	4.6
For over 5 years	2	0.9
Never	19	8.8
Does not know/did not answer	28	12.9
Total	217	100.0
Did you take the Pap smear?
Yes	125	57.6
No	42	19.4
Does not remember	13	6.0
Did not answer	37	17.1
Total	217	100.0
Have you ever had the HIV test in your life?
Yes	89	41.0
No	100	46.1
Did not answer	28	12.9
Total	217	100.0

Among the male participants (33), 11 (33.0%) had undergone postectomy, and 21 (63.6%) had undergone HIV testing at least once in the lifetime. Among the sexually active young men (30), only 1 (3.3%) had had sexual intercourse with women using the female condom. Table 3 presents the results of health care practices adopted by university students.

Table 3: Health care practices of male nursing undergraduates. Rio de Janeiro, 2015.

Questions - men only	f	%
Have you ever gone through surgery for phimosis or circumcision?
Yes	11	33
No	22	66.7
Total	33	100.0
Have you ever taken the HIV test in your life?
Yes	21	63.6
No	12	36.4
Total	33	100.0
Have you ever had sex with a woman using a female condom?
Yes	1	3.3
No	29	96.7
Total	30	100.0

Note: * Respondents to this question were only the sexually active participants

Discussion

The investigated group is composed, mainly, of young females between the ages of 18 and 21 years. The findings are in line with the Census of Higher Education of 2014, which indicates the predominance of women in higher education and the modal age of 21 among students in face-to-face courses.¹³Considering that the research was carried out with nursing students, authors point out that there is a predominance of women in the care process with construction of the profession.¹⁴

A research evaluated how changes in the work and income of parents affect young people in the choice between studying and working. It showed that the higher is the parents' income, the lower is the need to keep the children working during the training process.¹⁵ The findings of the present investigation evidenced that most of the students lived with their parents and did not work, especially, the participants of the public university. Furthermore, undergraduate training in these universities is given generally in full-time courses, and students are unable to reconcile work and the course. This fact makes the financial contribution of the family necessary during their training process.

Sexual activities are an inherent human practice and require maturity, responsibility and health care to reduce vulnerability to sexually transmitted infections. The initiation of sexual practices at an early age and without adequate guidance increases the exposure of young people to STIs, due to the lack of cognitive and emotional maturity of this population.⁸

In this study, the age range of the participants' onset of sexual activity was between 12 and 18, which is in line with studies that indicate the average age of sexual initiation in Brazil is 15 years.¹⁶It is added that this age group includes students of the first year of the course. During this time, they often experience various transformations in affective and sexual relationships, which may encourage greater alternation of sexual partners and favor their vulnerability to STIs.¹⁷

The continued use of condoms is the main method recommended by the Ministry of Health for prevention of STIs. In this research, it was found that, although most of the participants used this resource in the first sexual intercourse, they did not adopt it in all sexual intercourses, and this contributes to their exposure to infections transmitted through sexual contact. Research¹⁸ conducted with adolescents between the ages of 13 and 19 of a public school in Peruíbe-SP, aiming at comparing men and women as to vulnerability to HIV, showed that the frequency of condom use was higher among male students. On the other hand, condom use in all sexual intercourses was predominant among female students.^9,18

Most of the respondents reported having had sexual relationships with fixed partners and using condoms. However, a significant number of participants maintained casual relationships, and did not adopt the continuous use of condoms. The findings evidenced the use of condoms with fixed partnerships; however, other researches have shown that condoms were often neglected in this type of relationship. Studies^9,18-19 indicate that young people involved in long-term relationships (fixed partners) tend to devalue the use of condoms because they attribute such use to decreased pleasure during sexual intercourse or associate them with partner infidelity. The fear of harming the relationship is the main reason that drives individuals in monogamous relationships to neglect the use of condoms.

In the findings, it was observed that the male condom was more used by university students than the female condom, despite the fact that the group investigated was predominantly composed of women. A study¹⁹ that analyzed the reasons for non-adherence to the female condom revealed that women usually have difficulties in the use and handling of this device, besides the higher cost when compared to the male condom. Although the male condom is the most used resource, even in the groups of women, researches^18-19 indicate that fear and insecurity make it difficult for women to negotiate with their partners the use of condoms.

The HIV test is guaranteed by Ordinance 29, from December 17, 2013.²⁰ Although the male population is more prevalent in the realization of this test, studies show that access for women is greater when compared to men, and the search by women has increased, mainly among those with a better socioeconomic status.^21-22 Furthermore, basic health care units in Brazil offer rapid tests for the detection of HIV, acquired syphilis, and viral hepatitis B and C, in addition to providing treatment for people with positive diagnosis.

Regarding male circumcision, a research²³ identified that this procedure has a 40% to 60% protective effect on reducing the risk of exposure to HIV in heterosexual men in areas with high HIV prevalence (such as Africa). The research also demonstrated the benefits of circumcision for the prevention of urinary tract infections, HIV infection, transmission of some STIs (such as Human Papilloma Virus - HPV, and Herpes simplex virus type 2 - HSV2), and penile cancer.

Regarding the gynecological examination, 63% of the women surveyed had undergone the examination recently. However, studies,^22,24 indicate that the search for gynecological examinations has dropped due to lack of perception of risk, socioeconomic conditions, among others. It is important to emphasize that the Pap smear involves several factors that favor or not the adherence of women. For example, there is the educational work and embracement of health professionals, especially nurses, which favor the examination, as well as the presence of vaginal problems and/or medical recommendation. Shame, anxiety, fear and insecurity, however, are feelings that act as hindrances and favor the non-adherence of women to the examination. Health professionals play a fundamental role in this context, in mediating the needs of this population, offering assistance, guidance and clarification. Thus, individually or in groups, through the adoption of educational strategies and respect for the beliefs and culture of each woman, these workers can contribute significantly to adherence to the examination, making women aware of the importance of undergoing the preventive examination, as well as encouraging them to seek for health units.^22,24

The results obtained in this research are relevant and demonstrate the need to discuss the importance of safe sex practice for prevention of health problems such as STI with young people. Educational institutions have a fundamental role in this context. They contribute to the guidance of the students on diverse subjects, among them, sexuality.

It also noteworthy that health students, and particularly nursing students, have the opportunity to work during their training in various contexts, including primary health care. In this scenario, there is the Schools Health Program (SHP), carried out in partnership with the Ministry of Health and the Ministry of Education. Among other objectives, the SHP seeks to strengthen health promotion and disease prevention among students in basic education. In one of its dimensions, the program works with the permanent education and training of professionals and young people under the responsibility of the Open University of Brazil and the Ministry of Education. This activity has an interface with the Ministry of Health's Telehealth Centers and observes the themes and constitution of the teams that work in the territories of the Family Health Program units. It should be noted that, the monitoring and evaluation of the health of students to screen issues directly related to STI/Aids is foreseen in this dimension.²⁵

With this initiative, there is a clear intention of the Federal Government to offer students guidance on Health Education in the school context. This program, however, benefits only students of primary and secondary schools of public schools and attached to Family Health Strategy units. Young people from other educational institutions and universities are not included in the actions of the SHP, but they can participate in actions of the SHP as academics with scholarships. In the perspective of prevention of STI in the group of young people, it is important that the health care services be articulated with schools and universities, becoming spaces that favor the interlocution and interaction with students.

Considering that nurses play an important role in stimulating the sexual and reproductive health of young people, engaging in health education activities, and that their actions contribute to reducing the vulnerability of this group to STIs¹⁰, it is opportune that nursing students, as future nursing professionals, be encouraged to adopt safe sexual practices aiming at the preservation of their sexual health.

It is added that, in the context of individual vulnerability, the participants presented flaws in their sexual practices and sexual health care measures, as they did not adopt condoms consistently in all sexual intercourses, and even with casual partners. A significant number of young people (42%) had not performed the Pap smear recently. It is possible, therefore, that implicit factors interfere with the sexual practices and health care of young people.

Conclusion

The research counted on the participation of undergraduate nursing students. Considering that they were university students in the health area who have access to information on the prevention of sexually transmitted infections, it was expected that there would be a great adherence and continued use of condoms and adoption of care measures to protect sexual and reproductive health. Young men adopted the male condom more frequently with casual partners compared to fixed partners, and an expressive percentage of participants did not adopt the use of this device in all intercourses.

The results of this research showed that nursing students adopt risky behaviors in their sexual practices, and they resemble the pattern of sexual behavior of other young people in the same age group.

Health education practices conducted at universities could sensitize students to the importance of safe sex practices, encouraging the use of condoms on a continuous basis, even with long-term partners, and sexual health care. These actions could also contribute to reducing the vulnerability of university students to STIs and the assumption of sexual behavior focused on the preservation of sexual health.

The study presented as limitation the fact of being conducted only with nursing students. It would be opportune to replicate this research with students from other areas of knowledge, so as to compare the findings.

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Autor correspondente

Thelma Spindola

Email: tspindola.uerj@gmail.com

Address: Boulevard 28 de Setembro, 157 - Vila Isabel, Rio de Janeiro - RJ

Zip Code: 20551-030

Authorship contributions

1 – Thelma Spindola

Project design, data analysis and interpretation, article writing and critical review of intellectual content

2 – Carolina Passos Sodré

Data colletion, data analysis and interpretation, article writing.

3 - Cláudia Silvia Rocha Oliveira

Data analysis and interpretation, article writing and critical review of intellectual content

4- Barbara Ingenito de Oliveira

Data colletion, data analysis and interpretation, article writing.

5- Rosana Santos Costa Santana

Article writing and critical review of intellectual content

6- Nathalia Lourdes Nepomuceno de Oliveira André

Data colletion, data interpretation and article writing

How to cite this article

Spindola T, Sodré CP. Oliveira CSR, Oliveira BI, Santana RSC, André NLNO. Sexual practices and care related to sexual health of nursing students regarding sexually transmitted infections. Rev. Enferm. UFSM. 2019 [Available from: 2019 jun 15];vol ex:1-17-pf. DOI:https://doi.org/10.5902/217976923117