Revista Adolescência e Saúde

Revista Oficial do Núcleo de Estudos da Saúde do Adolescente / UERJ

NESA Publicação oficial
ISSN: 2177-5281 (Online)

Vol. 15 nº 4 - Oct/Dec - 2018

Review Article Imprimir 

Páginas 92 a 103


Interfaces of health education for HIV/AIDS prevention in young transgender women

Interfase de la Educación en Salud para la prevención del HIV/SIDA en mujeres transexuales jóvenes

Interface da Educação em Saúde para a prevenção do HIV/AIDS em mulheres transexuais jovens

Autores: Paula Daniella de Abreu1; Ednaldo Cavalcante de Araújo2; Eliane Maria Ribeiro de Vasconcelos3; Estela Maria Leite Meirelles Monteiro4; Firley Poliana da Silva Lúcio5; Betânia da Mata Ribeiro Gomes6

1. Master degree in Nursing bty the Nursin Department at the Federal University of Pernambuco (UFPE). Recife, PE, Brazil
2. Doctor in Nursing by the Federal University of São Paulo (UNIFESP). São Paulo, SP, Brazil. Professor of the Nursing Department at the Federal University of Pernambuco/UFPE and the Post-Graduation Program in Nursing (PPGENF). Recife, PE, Brazil
3. Dotor in Nursing by the Federal University of Santa Catarina (UFSC). Florianópolis, SC, Brazil. Professor of the post-graduation program in Nursing (PPGENF) at the UFPE. Recife, PE, Brazil
4. Doctor in Nursing by the Federal University of Ceará (UFC). Fortaleza, CE, Brazil. Professor of the post-graduation program in Nursing (PPGENF) at the UFPE. Recife, PE, Brazil
5. Master degree in Nursing by the Federal University of Pernambuco (UFPE).  Professor of the Nursing course in the Nursing Department at the UFPE. Recife, PE, Brazil
6. Doctor in Sciences in the line of research and Theoretical Basics to Care in the Inter-units Program of Doctorate by the Nursing School of Ribeirão Preto (EERP). Ribeirão Preto, SP, Brazil. Professor at the Faculty of Nursing Nossa Senhora das Graças/Department of Nursing at the Pernambuco University (FENSG/UPE). Recife, PE, Brazil

Paula Daniella de Abreu
Universidade Federal de Pernambuco
Avenida Professor Morares Rego, n°1235, Cidade Universitária
Recife, PE, Brasil. CEP: 50670-901
(pauladdabreu@gmail.com)

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How to cite this article

Keywords: Health education, HIV infections, transgender persons, health promotion, adolescent.
Palabra Clave: Educación en salud, infecciones por HIV, personas transgénero, promoción de la salud, adolescente.
Descritores: Educação em saúde, infecções por HIV, pessoas transgênero, promoção da saúde, adolescente.

Abstract:
OBJECTIVE: Analyze the scientific evidence about the strategies of Health Education for the prevention of HIV / AIDS in transgender women.
DATA SOURCE: Integrative literature review. The material was collected by searching the Capes portal: MEDLINE, SCOPUS, WoS and CINAHL. The following inclusion criteria were adopted: original articles published between 2011 and 2017 in English, Portuguese and Spanish. From the search strategy, 12.969 productions were identified, and 10 articles were selected. The data analysis was carried out using the R software for multidimensional analysis of texts and questionnaires.
DATA SYNTHESIS: The analysis revealed the following thematic categories: dialogic and participatory interventions for empowerment and community-based intersectoral actions.
CONCLUSION: It is considered that this theme demands greater visibility in order to contemplate and consolidate the scientific evidences in health that are focused on health education strategies, being innovative, participative and directed the needs of this group from childhood from the dynamics of the social network.

Resumen:
OBJETIVO: Analizar las evidencias científicas acerca de las estrategias de Educación en Salud para la prevención del VIH/SIDA en las mujeres transgénero.
FUENTE DE DATOS: Revisión integral de la literatura. El estudio del material fue realizado mediante búsqueda en el portal Capes: MEDLINE, SCOPUS, WoS y CINAHL. Los siguientes criterios de inclusión fueron: artículos originales publicados en el período de 2011 a 2017 en los idiomas: Inglés, portugués y español. A partir de la estrategia de búsqueda, se identificaron 12.969 producciones y de ellas se seleccionaron 10 artículos; el análisis de los datos se dio con el uso del software Interface de R, por los análisis multidimensionales de texto y de cuestionarios.
SÍNTESIS DE LOS DATOS: El análisis evidenció las siguientes categorías temáticas: intervenciones dialógicas y participativas para el empoderamiento y acciones intersectoriales de base comunitaria.
CONCLUSIÓN: Se consideró que esta temática demanda mayor visibilidad, a fin de contemplar y consolidar las evidencias científicas en el ámbito de la salud. Esta mayor visibilidad debe versar sobre estrategias de educación en salud, siendo de carácter innovador y participativo, y debe ser dirigida a las necesidades de este grupo desde la infancia a partir de la dinámica de la red social.

Resumo:
OBJETIVO: Analisar as evidências científicas acerca das estratégias de Educação em Saúde para a prevenção do HIV/AIDS em mulheres transgênero.
FONTES DE DADOS: Revisão integrativa da literatura. O levantamento do material foi realizado mediante a busca no portal Capes: MEDLINE, SCOPUS, WoS e CINAHL. Foram adotados os seguintes critérios de inclusão: artigos originais, publicados no período de 2011 a 2017, nos idiomas: Inglês, Português e Espanhol. A partir da estratégia de busca, foram identificadas 12.969 produções e destas foram selecionados 10 artigos, a análise dos dados se deu com o uso do software Interface de R, pelas análises multidimensionais de texto e de questionários.
SÍNTESE DOS DADOS: A análise evidenciou as seguintes categorias temáticas: intervenções dialógicas e participativas para o empoderamento e ações intersetoriais de base comunitária.
CONCLUSÃO: Considerou-se que esta temática demanda maior visibilidade, a fim de contemplar e consolidar as evidências científicas no âmbito da saúde. Esta maior visibilidade deve versar sobre estratégias de educação em saúde, sendo de caráter inovador e participativo, e deve ser direcionada às necessidades deste grupo desde a infância a partir da dinâmica da rede social.

INTRODUCTION

The interfaces between education and health oriented praxis in the field of public health for integrated care and covering the social dimension l understanding of the health/disease and extent of fair and democratic care process. This situation culminated in the construction of health education as the foundation of the innovative and emancipator well-being for the awakening of the critical individual and the collective conscience1.2.

Health education is based on two important pillars: the first one is the construction and propagation of the teachings and praxis intrinsic to the conception that each culture has about a healthy lifestyle; and the second one deals the formation of subjects and social identities, since these favor the development of critical thinking in order to promote the autonomy of the subject through dialogical debates and empowerment3.

Empowerment is a framework for the restructuring of public health policies based on the health promotion movement that emerged in Canada in 1974 and was disseminated worldwide since the first International Conference on the subject in Ottawa in 1986, which highlights the importance of health actions at the community level of popular participation in the construction of knowledge and the scope of the autonomy of health practices4.

Health promotion interventions at the community level should be linked to the recognition of the health / disease process with the influence of social determinants of health (housing, housing, work and education). The expanded vision of health involves changing paradigms to overcome the biological model, implies recognizing the impacts of social injustice, environmental insertion and interpersonal relationships. From this perspective, educational approaches, participatory nature, are destined to meet the specific needs of people through the social context3.5.

The basics of liberating education are covered by the National Policy for Health Promotion (PNPS) giving priority to the concept of expanded health of the articulation of social networks in order to promote human care or6. The actions of the network lead to the autonomy of the primary networks (family ties, kinship, friendship, neighborhood, work) and minimize the dependence on secondary networks (institutions, market organizations and third sector)7.

In order to foster the integration and humanization of health care LGBT group (Lesbian, Gay, Bisexual and Transgender), the Ministry of Health (MH) implemented actions to identity, body and mind of transgender people, by confronting discrimination. These actions are aimed at improving the process of continuing education for health professionals and the provision of specialized services for the Human Immunodeficiency Virus (HIV) and the Acquired Immune Deficiency Syndrome (AIDS) with the political organs of social participation8.

The goal for the confrontation of HIV / AIDS is inserted among the Millennium Development Goals proposed by the United Nations (UN) that reinforces the need for empowerment of people in situations of vulnerability, in accordance with the Universal Declaration of Human Rights that highlights the respect and protection of basic human rights in all areas of life, regardless of race, class, religion or culture9.

Discussing gender identity issues and building health education strategies for young transgender women requires overcoming limits resulting model hetero - exclusive, dichotomous suppressor regulatory sexual diversity. Therefore, the prevention of HIV/AIDS demands a holistic approach with a focus on the individual and the dynamics of the social network.

Health professionals must be able to develop educational activities in promoting the perspective of health and the articulation between popular knowledge and scientific knowledge to meet community demands10.

The ignorance of transgender about HIV, the vulnerability of these people in contracting and disseminating the virus and the lack of services that address these specificities demand a broad view on public health/health education/health service providers. In addition, stigma and harassment in health services ruled in an education for incipient health and lack of family support are the main obstacles that suppose the control of the virus and the quality of life of the people affected11.

The hetero normative socio cultural context and the marginalization condition of transsexual youth, through discriminatory behavior, have the potential to interfere in the dynamics of social insertion of these people. It is essential to understand the concept of social vulnerability for the construction of health education strategies, in order to motivate criticality, autonomy, the transformation of values and to build the stigma related to the idea of behavior and risk groups related to this population. In this sense, this study sought to answer the following guiding question: what are the national and international scientific evidence on health education for the prevention of HIV/AIDS in transgender women? This with the objective to analyze the scientific evidence about health education and strategies for the prevention of HIV/AIDS in transgender women.


METHOD

A bibliographic study was conducted with revision of integral type, which had as objective the construction of scientific knowledge in the area of health. The study aimed to enable the exploration of little known topics, in order to provide critical assessments through the practice of health professionals, based on scientific evidence. For this study, methodological rigor of problem definition, hypothesis, inclusion and exclusion criteria, categorization, analysis and presentation of included studies was necessary in order to provide important contributions to professional practice with a higher quality of care12.

For the construction of the revision integrates l were followed six stages: problem identification, setting criteria for inclusion and exclusion, which defines the information to be extracted to studies, assessment of the studies included in the review integrates l, interpretation of the results and the presentation of the review13.

From the identification of the guiding question, the data collection stage that was carried out in September 2017 in the following databases continued: Online System Search and Analysis of the Medical Literature Medical Literature Analysis and Retrieval System Online) - MEDLINE; SCOPUS; WEB OF SCIENCE; Cumulative Index to Nursing and Allied Health Lite - CINAHL. The search strategies were systematized according to access to databases, with the direction and purpose of the inclusion and exclusion criteria adopted.

The inclusion criteria were established: original articles published in the period from 2011 to 2017, in the languages: English, Portuguese and Spanish. As exclusion criteria: publications that did not respond to the study question; theses, dissertations, monographs, books. Chapters of books, summaries of congresses, annals, government programs and reports, review articles and duplicate publications (only one was counted).

The descriptions in english language used in database MEDLINE, Scopus, Web of Science and CINAHL were "Health Education" and "Transgender Persons" standardized by Descriptors in Health Sciences - DeCS and MedicalSubject Headings (MeSH) of the U.S. National Library of Medicine (NLM). In each base was crossed only with the term "AND", first pairs between descriptors and subsequently with three descriptors.

Each database was explored separately in english, portuguese and spanish, by crossing the controlled descriptors and is added to the period 2011-2017, and the lower temporal delimitation of the studies as of 2011 justifies the application of the National Policy of LGBT Integral Health . A total of 12,969 publications were identified from the exploratory reading of the titles and abstracts. We selected 142 articles that met the inclusion criteria, the objective of the study and answered the guiding question.

The next step involves assessing the level of evidence based in the category of the Agency for Healthcare Research and Quality (AHRQ), from the design of each study through the summary of the information in a systematic way using a tool that comprises the following levels:


Level 1: meta-analysis is of multiple studies controlled;

Level 2: individual study with experimental delineation;

Level 3: study with almost experimental delineation as a non- randomized study or with a single pre and post-test group, time series or case-control;

Level 4: study with non - experimental design as descriptive research and qualitative correlation or case studies;

Level 5: case report or give t or systematically obtained verifiable data quality or program evaluation;

Level 6: opinion of respected authorities based on clinical competence or opinion of expert committees, including interpretations of information not based on surveys.


Next, the adapted instrument was used Critical Appraisal Skills Program (CASP - Critical Reading Skills Program) for evaluation of methodological quality and the bias of Articles14. After the application of the instrument, two studies were excluded because they did not attend to the methodological rigor, being the others included in the synthesis and analysis of the data, as detailed in Figure 1.


Figure 1. Flow diagram of selection of the studies for the construction of integrated review l. Recife (PE), Brazil, 2017.



The final sample consisted of ten articles, classified according to the level of evidence15. All showed evidence of level 4, because they are analytical studies with quantitative approach (3) descriptive studies with quantitative approach (3), qualitative years (3) mixed (1), all published in english.

ID: to facilitate data collection, a validated instrument aimed to review studies integrates l for maximum extraction of the results considering the following items was used authors, article title and year of publication; methodological characteristics of the study: objectives and type of publication16. To evaluate the quality of the pre-selected articles, the adapted instrument (CASP) was used, classifying the articles in two concepts: A) 6 to 10 points - studies of good methodological quality and reduced bias; B) at least 5 points - studies with satisfactory methodological quality, but with increased bias potential. In this study, it was decided to use the concept with articles14.

For the analysis of the ten articles included in this review, the software of R interface for the multidimensional analysis of text and questionnaires (IRAMUTEQ) version 7.0. This is a program that ensures accuracy and analysis of methodological similarity allows semantic comprehension of words17.

The corpus The text analyzed by the results emerged is shown in Figure 2 and shows the interface of the results of the analysis of similarity with the evaluation of co-occurrences between the words that appear in the selected studies, the indications of the connectivity between the terms: HIV prevention, risk, woman, transgender, social intervention, address , strategy, community, population, providing the field of representation of health education strategies on the basis of participation interventions of transgender women under the scrutiny of current social and health demands.


Figure 2. Synthesis of the results found in the articles selected in the integrated review l. Recife (PE), Brazil, 2017



RESULTS

It was identified that the selected articles were published in national and international journals. As for the methodology, the articles that have composed the final sample have quantitative focus (6) Qualitative (3) and mixed methods (1), evidence level 4. These mentioned n health education from participatory approaches and innovative methodologies.

After the analysis, it was possible to perceive that the construction of the competence tree resulting from the scientific evidence addressed aspects concerning the health education process through the social network of transgender women, thus allowing dialogical and participatory interventions in the transgender group to be highlighted as elements of the primary network, and community-based intersectoral actions as elements of the secondary network. So, the configuration of the networks mentioned in the studies integrates the social dynamics for the prevention of HIV / AIDS in transgender women.

Tables 1 and 2 below present the publications of the articles inserted in categories I and II, and contemplate the authors, location, year, title, objective, type of study and level of evidence of the publications referring to each category. Category I articles emphasize dialogical and participatory interventions for empowerment, and category II articles deal with community-based intersectoral actions.






DISCUSSION

For the understanding of health education of transgender women on the prevention of HIV/AIDS, it is necessary to discuss scientific evidence on effective interventions through the set of relationships built in the community level under the criteria of gender identity. In this context, social relations govern the dynamic of support and containment that determine the limits of the autonomy of the person in a situation of social vulnerability7.

The content presented in the selected studies elucidated health education actions based on critical-reflective analysis of the reality of transgender women. The studies addressed the need for peer empowerment in a participatory, dialogical and democratic manner. They also emphasize that the actions of protection community are necessary for changes conception, being the flow of shares in the social network the foundation for comprehensive care for transgender women. After the analysis of similarity of the corpus, the terms evidenced or proposed the construction of thematic categories:

Category 1: Dialogical and participatory interventions for empowerment

The overall image of young transsexual women is social injustice, prejudice, marginalization and vulnerability to HIV/AIDS28. Through the historical, social and cultural context associated with heteronormative hegemony, critical and reflexive analysis of reality is essential for the construction of health education strategies with a view to empowering this group of the society.

The construction of health promotion strategies through dialogue and interaction allows mutual support among equals and the empowerment of women Transgender18. To overcome the stigma associated with the idea of risk behavior side by side with individual guilt, it is essential to recognize that it limits the channels of protection from vulnerability to HIV/AIDS29.

In the case of transgender women in various social settings, the thematic approach on sexuality needs to be inclusive, clarifying issues on the construction of gender identity, masculinity/femininity and sexual diversity in order to unveil taboos and expand criticality for the school, family, community and health system environment30,31.

The lack of family support and school evasion result in extreme social exclusion with repercussion on limits for the insertion of transgender women in the labor market, being "sex job" the main alternative for the acquisition of income. Innovative strategies to prevent HIV/AIDS beyond the idea of risk behavior and enters the social environment, living conditions and working conditions, which influence the disease process and vulnerability to viruses19.32.

The dialogical interventions focused interventions give in pairs are effective strategy to prevent HIV/AIDS and guiding the dynamics of relationship, dialogue, exchange of knowledge and seizures20. For the limited number of transgender women by providing education and work, building actions focused given in revenue generation it is essential, including discussions on vocational training, financial education and overcoming potential social barriers in building social context of the life project19 ,21.

The results of this review suggest that thematic approaches to the discussions should be structured for social resilience and should assess the limits and impacts produced by exclusion from the health/disease process and vulnerability to HIV/AIDS of transgender women22. Health education strategies of social participation are the necessary arrangements to ensure the human rights of vulnerable populations, and determining axes to make decisions based on acceptance and appreciation of their demands33.

Category 2: Community-based intersectoral actions

Health education practices reorient the way of thinking and acting with a view to the effectiveness of social and health rights. In this perspective, the epistemological praxis for popular health education based on the exchange of socially constructed and shared knowledge constitutes a necessary foundation for the confrontation of problems. The empowerment and autonomy of individuals and groups of dialogical and democratic resources will contribute to strengthening n social movements and guarantee human rights guarantees34.

The prevention of HIV/AIDS at the community level is transmitted fundamentally to knowledge and practices built by a social conscience influenced by heteronormative patterns that suppress sexual diversity35. The construction of values and the consolidation of paradigms related to the expressions of sexuality and gender identity demand the responsibility of decision making, confrontation and quality of life30.

Health promotion actions should be structured in accordance with the language of the transgender public, free of heteronormative paradigms. It gives the actors of the education and health networks for joint actions, construction and implementation of innovative and comprehensive ideas in favor of sexual diversity in the development of debate and construction of projects related to sex education36.

The actions of confronting HIV/AIDS must agree with the culture, social context and peculiarities of transgender women. The articulation of care to the dynamics of social networks of these people is essential. Therefore, the effectiveness requires offering for HIV/AIDS is not limited to individual behavior, but l wider social context23.

The collective dialogue in different social scenarios reveals the culture of the networks; the shared sense is attributed to the conceptions and options of each individual7. The offer of programs directed towards transgender women that deal with the wide dissemination of information, rapid tests for HIV, community-based services for awareness raising in community premises (bars, clubs, boutiques, parks, street corridors, avenues, hotels and hair stores) and nails) must be culturally coherent with the target24,25.

The network strategies produced from the axes of intervention require systematic actions to conduct an integral approach centered on the collective dimension of the problems7. The educational actions can count on the offer of tests, workshops, stimulation to the self-care and action of the social networks, with the use of dialogical resources and educational technologies. These techniques contribute to the fight against social stigma and positive attitudes26.

The social mobilization of the actors that make up the network begins with the implementation of a social intervention project of the collective dimension and continues to take extended autonomy in the primary networks in relation to the secondary networks7. The construction of survival strategies for HIV/AIDS of transgender people requires overcoming prejudices with experience and the contribution of the social network of the community of motivation - interventions based on autonomous decision-making and improving the quality of life27,37.


FINAL CONSIDERATIONS

It is considered that the objective proposed in this comprehensive review was achieved, since the scientific evidences about health education strategies for the prevention of HIV / AIDS in transgender women were analyzed.

The categories that emerged from this study revealed the educational resources for the consolidation of preventive and integral health care for transgender women. The thematic approach should arise from the interest and needs of the target audience, in addition to demystifying the taboos regarding sexuality, the historicity about gender identity, the discussions on the expression of sexual diversity, the practice of safe sex and the social empowerment, which are topics that can mediate debates.

There was a lack of scientific evidence, especially from national ones, which deal with the context of vulnerability to HIV/AIDS and health education strategies to deal with this epidemic, in accordance with the specificities of young transgender people. In this sense, it is suggested that this topic be more visible in the academic and health care curricula, in addition to the construction of educational technologies and experimental studies with a social impact.


ACKNOWLEDGMENT NOTE

To Prof. Dr. Claudia Benedita dos Santos, from the School of Nursing of Ribeirão Preto, University of São Paulo - Postgraduate Program in Nursing in Public Health, for the valuable collaboration in this manuscript.


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